Subcutaneously administered anti-il-6 receptor antibody

ABSTRACT

The present application discloses methods for treating an IL-6-mediated disorder such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), systemic JIA (sJIA), polyarticular course JIA (pcJIA), systemic sclerosis, or giant cell arteritis (GCA), with subcutaneously administered antibody that binds interleukin-6 receptor (anti-IL-6R antibody). In particular, it relates to identification of a fixed dose of anti-IL-6R antibody, e.g. tocilizumab, which is safe and effective for subcutaneous administration in patients with IL-6-mediated disorders. In addition, formulations and devices useful for subcutaneous administration of an anti-IL-6R antibody are disclosed.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a Division of U.S. application Ser. No. 16/254,105,filed Jan. 22, 2019, which is a division of U.S. application Ser. No.15/668,445 filed on Aug. 3, 2017 (now U.S. Pat. No. 10,231,981) which isa division of U.S. application Ser. No. 14/062,026, filed Oct. 24, 2013(now U.S. Pat. No. 9,750,752) which is a division of U.S. applicationSer. No. 13/290,366, filed Nov. 7, 2011 (now U.S. Pat. No. 8,580,264),which claims priority under 35 USC § 119(e) to U.S. ProvisionalApplication Ser. No. 61/411,015, filed on Nov. 8, 2010 and U.S.Provisional Application Ser. No. 61/542,615, filed on Oct. 3, 2011,which are incorporated by reference in entirety.

SEQUENCE LISTING

The instant application contains a Sequence Listing submitted viaEFS-Web and is hereby incorporated by reference in its entirety. SaidASCII copy, created Dec. 1, 2020, is namedP04494_US_8_Sequence_Listing.txt, and is 7,498 bytes in size.

FIELD OF THE INVENTION

The present application concerns methods for treating an IL-6-mediateddisorder such as rheumatoid arthritis (RA), juvenile idiopathicarthritis (JIA), systemic JIA (sJIA), polyarticular course JIA (pcJIA),systemic sclerosis, or giant cell arteritis (GCA), with subcutaneouslyadministered antibody that binds interleukin-6 receptor (anti-IL-6Rantibody). In particular, it relates to identification of a fixed doseof anti-IL-6R antibody, e.g. tocilizumab, which is safe and effectivefor subcutaneous administration in patients with IL-6-mediateddisorders. In addition, formulations and devices useful for subcutaneousadministration of an anti-IL-6R antibody are disclosed.

BACKGROUND OF THE INVENTION

Rheumatoid arthritis is a progressive, systemic autoimmune diseasecharacterized by synovitis that damages diarthroidal joints and isaccompanied by fatigue, anemia, and osteopenia. Rheumatoid arthritis hasa prevalence of 0.5% to 1.0% (Silman, A. J. “Epidemiology and therheumatic diseases.” In: Maddison P J, Isenberg D A, Woo P, Glass D N,eds. Oxford Textbook of Rheumatology: Oxford University Press: 499-513(1993)) and a peak incidence between 40 and 60 years of age and affectsprimarily women. The cause of RA is not known; however, certainhistocompatibility antigens are associated with poorer outcomes.Nonsteroidal anti-inflammatory drugs (NSAIDs) provide only symptomaticrelief. Disease-modifying antirheumatic drugs (DMARDs), the cornerstoneof RA treatment throughout all stages of the disease (Maddison et al.,supra), maintain or improve physical function and retard radiographicjoint damage (Brooks, P. M. “Clinical Management of rheumatoidarthritis.” Lancet 341: 286-290 (1993)). More recently, biologicalcompounds that target tumor necrosis factor alpha (TNF-α), B-cells, orT-cells have been used successfully to treat RA, but ˜30% to 40% ofpatients fail to respond to these therapies (Bathon et al. New Eng. J.Med. 343: 1586-1592 (2000); Maini et al. Arthritis & Rheumatism 41:1552-1563 (1998)).

Interleukin-6 (IL-6) is a proinflammatory, multifunctional cytokineproduced by a variety of cell types. IL-6 is involved in such diverseprocesses as T-cell activation, B-cell differentiation, induction ofacute phase proteins, stimulation of hematopoietic precursor cell growthand differentiation, promotion of osteoclast differentiation fromprecursor cells, proliferation of hepatic, dermal and neural cells, bonemetabolism, and lipid metabolism (Hirano T. Chem Immunol. 51:153-180(1992); Keller et al. Frontiers Biosci. 1: 340-357 (1996); Metzger etal. Am J Physiol Endocrinol Metab. 281: E597-E965 (2001); Tamura et al.Proc Natl Acad Sci USA. 90:11924-11928 (1993); Taub R. J Clin Invest112: 978-980 (2003)). IL-6 has been implicated in the pathogenesis of avariety of diseases including autoimmune diseases, osteoporosis,neoplasia, and aging (Hirano, T. (1992), supra; and Keller et al.,supra). IL-6 exerts its effects through a ligand-specific receptor(IL-6R) present both in soluble and membrane-expressed forms.

Elevated IL-6 levels have been reported in the serum and synovial fluidof RA patients, indicative of production of IL-6 by the synovium (Iranoet al. Eur J Immunol. 18:1797-1801 (1988); and Houssiau et al. ArthritisRheum. 1988; 31:784-788 (1988)). IL-6 levels correlate with diseaseactivity in RA (Hirano et al. (1988), supra), and clinical efficacy isaccompanied by a reduction in serum IL-6 levels (Madhok et al. ArthritisRheum. 33:S154. Abstract (1990)).

Tocilizumab (TCZ) is a recombinant humanized monoclonal antibody of theimmunoglobulin IgG1 subclass which binds to human IL-6R. Clinicalefficacy and safety studies of intravenous (IV) TCZ have been completedor are conducted by Roche and Chugai in various disease areas, includingadult-onset RA, systemic juvenile idiopathic arthritis and polyarticularjuvenile idiopathic arthritis.

TCZ 8 mg/kg IV has been approved in over 70 countries for use in RA,including Japan and Europe. In the United States, TCZ W (4 mg/kg and 8mg/kg) has been approved in RA patients who have had an inadequateresponse to anti-TNF agents. Additionally, TCZ was approved for use inCastleman's disease in India and Japan.

On Apr. 15, 2011, the U.S. Food and Drug Administration approved TCZ,given alone or in combination with methotrexate, for the treatment ofactive systemic juvenile idiopathic arthritis (sJIA) (US Package Insert(USPI) for TCZ ACTEMRA®, April 2011). On Aug. 1, 2011, TCZ was alsoapproved in the EU for the treatment of active sJIA who have respondedinadequately to previous therapy with NSAIDs and systemiccorticosteroids (CS), and TCZ can be given as monotherapy (in case ofintolerance to MTX or where treatment with MTX is inappropriate) or incombination with MTX in patients 2 years of age and older (Summary ofProduct Characteristics (SmPC) for RoACTEMRA, Roche Registration Limited6 Falcon Way Shire Park, Welwyn Garden City, AL7 1TW, United Kingdom, 4Jun. 2010). The approved TCZ dose for sJIA patients weighing <30 kg is12 mg/kg TCZ, and for patients weighing ≥30 kg is 8 mg/kg IV infusionevery 2 weeks.

TCZ has been approved for treatment of polyarticular course juvenileidiopathic arthritis (pcJIA) in Japan based on the phase 3 studyMRA318JP conducted in Japanese patients. WA19977 is an ongoing pivotalphase 3 study investigating the efficacy, safety, PK and PD of TCZ inchildren with pcJIA age of 2 to 17 years old.

TCZ has been intravenously administered to 2 Japanese patients withdiffuse cutaneous systemic sclerosis (SSc) (Shima et al. Rheumatology49:2408-12 (2010), doi:10.1093/rheumatology/keq275)), and to 5 patientswith SSc (Meunier et al. Ann. Rheum. Dis. 70(Suppl 3):660 (2011)). Inpatients with SSc, elevated levels of circulating IL-6 have beenreported, particularly in patients with early disease. IL-6 isoverexpressed in endothelial cells and fibroblasts of involved skin inpatients with SSc (Koch et al. Pathobiology 61:239-46 (1993)). ElevatedIL-6 levels have been detected in the bronchioalveolar lavage ofpatients with SSc. Dermal fibroblasts from patients with SSc have beenreported to constitutively express higher levels of IL-6 compared withthose of healthy controls (Kadono et al. J. Rheumatol. 25:296-301(1998)). In addition, serum IL-6 levels correlate positively with skinsclerosis and acute-phase proteins (Ong and Denton, Curr. Opin.Rheumatol. 22:264-72 (2010)).

IL-6 has first been described as a potent growth and maturation factorfor developing human plasma cells. IL-6 induces B-cell proliferation,antibody secretion, and survival of plasmablasts. Activated B cellsproduce IL-6 and other cytokines. In patients with SSc, polyclonalB-cell activation, presence of highly specific autoantibodies, andB-lymphocyte infiltration in diseased skin of patients have beendetected. However, open-label trials of B cell-depleting antibodies inpatients with SSc have resulted in inconclusive data to date (Bosello etal. Arthritis Res. Therapy 12:R54 (2010); Layfatis et al. ArthritisRheum. 60: 578-83 (2009); Daoussis et al. Rheumatology 49:271-80(2010)). Bosello et al. (2010) reported beneficial effects of B-celldepletion for patients with SSc that were associated with a reduction ofserum IL-6 levels. In addition to its effects on B-cell function, IL-6has specific effects on T cells. IL-6 promotes T-cell survival andTh17-lymphocyte differentiation and inhibits development of regulatory Tcells. Th17 cells produce IL-17 and have been linked to development ofautoimmune diseases. In an autocrine loop, IL-17 may induce IL-6synthesis in human fibroblasts (Fossiez et al. J. Exp. Med.813:2593-2603 (1996)). Increased circulating Th17 cells have alsorecently been reported in patients with SSc (Radstake et al. PLoS ONE4(6):e5903. doi:10.1371/journal.pone.0005903. Atamas S P Life Sci72:631-43 (2009)), whereas serum and bronchioalveolar lavage levels ofIL-17 were found to be increased in patients with SSc and ILD (Kurasawaet al. Arthritis Rheum 43: 2455-63 (2000)).

Fibrosis gradually replaces the inflammatory phase of SSc. In vitroexperiments with human dermal fibroblast cultures showed that IL-6increased collagen type I, glycosaminoglycans, hyaluronic acid, andchondroitin sulfate production (Duncan and Berman J. Invest. Dermatol.97:686-92 (1991)).

Giant cell arteritis (GCA) is a primary vasculitis involving large andmedium sized arteries which is typically diagnosed by temporal arterybiopsy. Signs and symptoms of GCA include elevated erythrocytesedimentation rate (ESR) or new headaches. Adverse sequelae include:irreversible blindness (bilateral retinal or optic nerve ischemia),infarcation of brain, tongue, upper limb, or aortic aneurysm. GCA is anunmet medical need. High dose corticosteroids (CS) are the currentstandard of care, but more durable remissions are needed (50% ofpatients relapse), and steroid sparing treatment options are needed inview of steroid-related complications). Case studies reporting the useof TCZ in giant cell arteritis are: Seitz et al. Swiss Med Wkly141:w13156 pgs. E1-E4 (2011); Salvarani et al. Arth. and Rheum. (April2011); and Beyer et al. Ann. Rheum. Dis. pgs. 1-2 (2011),doi:10.1136/ard.2010.149351. In each of these studies TCZ wasadministered intravenously.

Patents and patent publications related to anti-IL-6R antibodiesinclude: U.S. Pat. No. 5,171,840 (Kishimoto), U.S. Pat. No. 5,480,796(Kishimoto), U.S. Pat. No. 5,670,373 (Kishimoto), U.S. Pat. No.5,851,793 (Kishimoto), U.S. Pat. No. 5,990,282 (Kishimoto), U.S. Pat.No. 6,410,691 (Kishimoto), U.S. Pat. No. 6,428,979 (Kishimoto), U.S.Pat. No. 5,795,965 (Tsuchiya et al.), U.S. Pat. No. 5,817,790 (Tsuchiyaet al.), U.S. Pat. No. 7,479,543 (Tsuchiya et al.), US 2005/0142635(Tsuchiya et al.), U.S. Pat. No. 5,888,510 (Kishimoto et al.), US2001/0001663 (Kishimoto et al.), US 2007/0036785 (Kishimoto et al.),U.S. Pat. No. 6,086,874 (Yoshida et al.), U.S. Pat. No. 6,261,560(Tsujinaka et al.), U.S. Pat. No. 6,692,742 (Nakamura et al.), U.S. Pat.No. 7,566,453 (Nakamura et al.), U.S. Pat. No. 7,771,723 (Nakamura etal.), US 2002/0131967 (Nakamura et al.), US 2004/0247621 (Nakamura etal.), US 2002/0187150 (Mihara et al.), US 2005/0238644 (Mihara et al.),US 2009/0022719 (Mihara et al.), US 2006/0134113 (Mihara), U.S. Pat. No.6,723,319 (Ito et al.), U.S. Pat. No. 7,824,674 (Ito et al.), US2004/0071706 (Ito et al.), U.S. Pat. No. 6,537,782 (Shibuya et al.),U.S. Pat. No. 6,962,812 (Shibuya et al.), WO 00/10607 (Akihiro et al.),US 2003/0190316 (Kakuta et al.), US 2003/0096372 (Shibuya et al.), U.S.Pat. No. 7,320,792 (Ito et al.), US 2008/0124325 (Ito et al.), US2004/0028681 (Ito et al.), US 2008/0124325 (Ito et al.), US 2006/0292147(Yoshizaki et al.), US 2007/0243189 (Yoshizaki et al.), US 2004/0115197(Yoshizaki et al.), US 2007/0148169 (Yoshizaki et al.), U.S. Pat. No.7,332,289 (Takeda et al.), U.S. Pat. No. 7,927,815 (Takeda et al.), U.S.Pat. No. 7,955,598 (Yoshizaki et al.), US 2004/0138424 (Takeda et al.),US 2008/0255342 (Takeda et al.), US 2005/0118163 (Mizushima et al.), US2005/0214278 (Kakuta et al.), US 2008/0306247 (Mizushima et al.), US2009/0131639 (Kakuta et al.), US 2006/0142549 (Takeda et al.), U.S. Pat.No. 7,521,052 (Okuda et al.), US 2009/0181029 (Okuda et al.), US2006/0251653 (Okuda et al.), US 2009/0181029 (Okuda et al.), US2007/0134242 (Nishimoto et al.), US 2008/0274106 (Nishimoto et al.), US2007/0098714 (Nishimoto et al.), US 2010/0247523 (Kano et al.), US2006/0165696 (Okano et al.), US 2008/0124761 (Goto et al.), US2009/0220499 (Yasunami), US 2009/0220500 (Kobara), US 2009/0263384(Okada et al.), US 2009/0291076 (Morichika et al.), US 2009/0269335(Nakashima et al.), US 2010/0034811 (Ishida), US 2010/0008907 (Nishimotoet al.), US 2010/0061986 (Takahashi et al.), US 2010/0129355 (Ohguro etal.), US 2010/0255007 (Mihara et al.), US 2010/0304400 (Stubenrach etal.), US 2010/0285011 (Imaeda et al.), US 2011/0150869 (Mitsunaga etal.), WO 2011/013786 (Maeda) and US 2011/0117087 (Franze et al.).

SUMMARY OF THE INVENTION

In a first aspect, the invention concerns a method of treating anIL-6-mediated disorder in a patient comprising subcutaneouslyadministering an anti-IL-6 receptor (IL-6R) antibody to the patient,wherein the anti-IL-6R antibody is administered as a fixed dose of 162mg per dose (e.g. administered every week or every two weeks).Embodiments of the disorder include: rheumatoid arthritis (RA), juvenileidiopathic arthritis (JIA), psoriatic arthritis, and Castleman'sdisease. Preferably, the anti-IL-6R antibody is tocilizumab.

The invention also concerns a method of treating rheumatoid arthritis ina patient comprising subcutaneously administering tocilizumab to thepatient, wherein the tocilizumab is administered as a fixed dose of 162mg per dose every week or every two weeks.

In another embodiment, the invention provides an article of manufacturecomprising a subcutaneous administration device, which delivers to apatient a fixed dose of an anti-IL-6 receptor (IL-6R) antibody, whereinthe fixed dose is selected from the group consisting of 162 mg, 324 mg,and 648 mg of the anti-IL-6R antibody.

The invention, in another aspect, concerns a method of inhibitingprogression of structural joint damage in a rheumatoid arthritis patientcomprising subcutaneously administering a fixed dose of 162 mg of ananti-IL-6R antibody to the patient every two weeks, wherein structuraljoint damage at week 24 or week 48 is found to be inhibited.

In addition, the invention provides a pharmaceutical compositioncomprising: an anti-IL-6R antibody in an amount from about 100 mg/mL toabout 300 mg/mL, and hyaluronidase enzyme in an amount from about 1,400to about 1,600 U/mL.

In further aspects, a method of treating an IL-6-mediated disorder in apatient is provided comprising subcutaneously administering suchpharmaceutical composition to the patient, wherein the anti-IL-6Rantibody is administered as a fixed dose of 324 mg per dose or 648 mgper dose, e.g. where the fixed dose is administered every four weeks oronce every month.

The invention also concerns a method of treating an IL-6-mediateddisorder in a patient comprising subcutaneously administering ananti-IL-6R antibody and a hyaluronidase enzyme to a patient, wherein theanti-IL-6R antibody is administered as a fixed dose of 324 mg per doseor 648 mg per dose (e.g. every four weeks or once every month).

The invention also concerns subcutaneously administering an anti-IL-6Rantibody (e.g. tociluzumab) to a patient with an IL-6-mediated disorder.Examples of such disorders include: autoimmune diseases, osteoporosis,neoplasia, aging, rheumatoid arthritis (RA), juvenile idiopathicarthritis (JIA), systemic JIA (sJIA), polyarticular course JIA (pcJIA),psoriatic arthritis, Castleman's disease, Crohn's disease, multiplemyeloma, polymyalgia rheumatica, glomerulonephritis, plasmacytoma orplasmacytosis, myeloma (including multiple myeloma),hyperimmunoglobulinemia, anemia, nephritis (such as mesangiumproliferative nephritis), cachexia (including cancerous cachexia),tumors, T cell mediated disease (e.g. uveitis, chronic thyroiditis,delayed hypersensitivity, contact dermatitis, or atopic dermatitis),lupus (including lupus nephritis and systemic lupus erythmatosus),inflammatory bowel disease (including Crohn's disease and ulcerativecolitis), pancreatitis, psoriasis, osteoarthritis, adult-onset Still'sdisease, mesothelioma, vasculitis, islet transplantation (e.g.pancreatic islet transplantation), myocardial infarction (heart failure,ischemia-induced severe arrhythmia), heart transplantation, prostatecancer, choroidal neovascularization (e.g. age-related maculardegeneration, idiopathic choroidal neovascularization, cyopic choroidalneovascularization, idiopathic choroidal neovascularization), muscleatrophy, chronic rejection, ocular inflammatory disease (e.g.panuveitis, anterior aveitis, intermediate uveitis, scleritis,keratitis, orbital inflammation, optic neuritis, dry eye, diabeticretinopathy, proliferative vitreoretinopathy, postoperativeinflammation), graft versus host disease (GVHD), fibrotic disorders(such as systemic sclerosis), giant cell arteritis (GCA), Takayasu'sarteritis (TA), arteritis nodosa, ankylosing spondylitis, etc.

Optionally, the disorder is rheumatoid arthritis, juvenile idiopathicarthritis (JIA), systemic JIA (sJIA), polyarticular course JIA (pcJIA),giant cell arteritis (GCA), or systemic sclerosis.

In one embodiment, the anti-IL-6R antibody is subcutaneouslyadministered to the patient with the IL-6-mediated disorder as a fixeddose of 162 mg per dose, wherein the fixed dose is subcutaneouslyadministered every week, every two weeks, or every 10 days.

In a further aspect, the invention concerns a method of treatingjuvenile idiopathic arthritis (JIA) in a patient comprisingsubcutaneously administering an anti-IL-6 receptor (IL-6R) antibody tothe patient in an amount effective to treat the JIA.

Additionally, a method of treating a fibrotic disease (e.g. systemicsclerosis) in a patient is provided which comprises subcutaneouslyadministering an anti-IL-6 receptor (IL-6R) antibody to the patient inan amount effective to treat the fibrotic disease.

Moreover, the invention concerns a method of treating giant cellarteritis (GCA) in a patient comprising subcutaneously administering ananti-IL-6 receptor (IL-6R) antibody to the patient in an amounteffective to treat the GCA.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts mean sIL-6R concentration-time profiles followingadministration of TCZ 162 mg SC QW/Q2W in Japanese (MRA227) andCaucasian (NP22623) RA patients compared with TCZ 4 & 8 mg IV Q4W(WA17823). Key: Japanese RA patients MRA227 study: N=12 for the 162 mgQW group, N=12 for 162 mg Q2W group and N=6 to 8 for the 81 mg QW/Q2Wgroup which had a single dose part of 3 weeks. For the 81 mg group, theregimen was switched from Q2W to QW at week 9; Caucasian RA patients inNP22623 study: N=13 for 162 mg Q2W and N=14 for QW group. WA17823 study:N=146 for 4 mg/kg IV Q4W and N=532 or 8 mg/kg IV in combination withMTX. Error bar denotes standard deviation.

FIG. 2 depicts mean CRP-time profiles following administration of TCZ162 mg QW/Q2W SC in Japanese (MRA227) and Caucasian (NP22623) RApatients compared with the profile of 4 & 8 mg/kg IV Q4W (WA17822). Key:Japanese RA patients in MRA227 study: N=12 for the 162 mg QW group, N=12for the 162 mg Q2W group and N=8 up to week 11 and N=7 thereafter forthe 81 mg Q2W/QW group including the single dose part of 3 weeks. Forthe 81 mg group, the regimen was switched from Q2W to QW at week 9;Caucasian RA patients in NP22623 study: N=13 for 162 mg Q2W and N=14 forQW group. WA17822 study: N=152 to 211 for 4 mg/kg IV Q4W and N=167 to206 for 8 mg/kg IV in combination with MTX. ULN-Upper limit of normalrange.

FIG. 3 depicts change in DAS28-ESR from baseline followingadministration of TCZ in SC studies (MRA227 and NP22623) and in W Study(WA17822). Key: Japanese SC study in RA patients (MRA227): N=12 for the162 mg QW group, N=12 for 162 mg Q2W group and N=8 up to week 11 and N=7thereafter for the 81 mg Q2W/QW group including the single dose part of3 weeks. For the 81 mg group, the regimen was switched from Q2W to QW atweek 9; Caucasian SC study in RA patients (NP22623): N=11 for the 162 mgQ2W group+MTX QW and N=12 for the 162 mg QW+MTX QW group. Comparatorstudy WA17822: N=152 to 211 for the 4 mg/kg Q4W+MTX QW group, and N=167to 206 for 8 mg/kg Q4W+MTX QW group.

FIG. 4 depicts mean±SD serum TCZ concentrations following administrationof 162 mg SC QW and Q2W in Study MRA227 and 4 & 8 mg/kg IV Q4W in StudyLRO301. Key: Group 1 (N=8 up to week 11 and N=7 thereafter): patientsreceived 81 mg SC single dose at week 1, started Q2W dosing at week 3,and switched to Q2W dosing at week 9; Group 2 (162 mg Q2W, N=12):patients received single 162 mg SC dose at week 1 and started Q2W dosingat week 3; Group 3 (162 mg QW, N=12): patients received 162 mg QW dosingfor 15 weeks until the data-cut. Caucasian SC Study in RA patients(NP22623): N=13 for the 162 mg Q2W group+methotrexate (MTX) QW and N=14for the 162 mg QW+MTX QW group. PK profiles from 4 and 8 mg/kg IVinfusion every 4 weeks in RA patients in the Phase 2 dose-finding studyLRO301 are illustrated for comparison. LRO301 was selected forcomparison as PK from phase 2 and phase 3 studies were similar and Phase3 had infrequent PK sampling (an observed mean PK profile could not beconstructed appropriately).

FIG. 5 depicts WA22762 Study Design as in Example 2.

FIG. 6 depicts NA25220B Study Design as in Example 3.

FIGS. 7A and 7B depict the amino acid sequences of the light chain (FIG.7A; SEQ ID NO:1) and heavy chain (FIG. 7B; SEQ ID NO:2) of Tocilizumab.

FIGS. 8A and 8B depict mean (±SD) Tocilizumab concentration-time profileby cohort for the study in Example 5. FIG. 8A provides linear scale;FIG. 8B provides log-linear scale. TCZ=tocilizumab; TCZ/PH20=tocilizumabco-formulated with rHuPH20.

FIGS. 9A and 9B depict dose proportionality for Tocilizumab/rHuPH20AUC_(0-inf.) (FIG. 9A) and C_(max) (FIG. 9B).

FIG. 10 depicts mean (±SEM) CRP concentration-time plot by cohort.TCZ=tocilizumab; TCZ/PH20=tocilizumab co-formulated with rHuPH20.

FIG. 11 depicts mean (±SEM) IL-6 concentration-time plot by cohort.TCZ=tocilizumab; TCZ/PH20=tocilizumab co-formulated with rHuPH20.

FIG. 12 depicts mean (±SEM) sIL-6R concentration time plot by cohort.TCZ=tocilizumab; TCZ/PH20=tocilizumab co-formulated with rHuPH20.

FIG. 13 compares IV PK profiles following 4 and 8 mg/kg every 4 Weekswith SC PK profiles following 324 mg TCZ/rHuPH20 and 648 mg TCZ/rHuPH20Administration (The W data for 4 and 8 mg/kg are from study LR0320).TCZ=tocilizumab; TCZ/PH20=tocilizumab co-formulated with rHuPH20.

FIGS. 14A and 14B depict PK profiles following intravenous (IV)(simulated for WA18221 FIG. 14A) and subcutaneous (SC) administration(simulated for the patients from WA18221, FIG. 14B).

FIG. 15 model predicted Cmin for study WA18221 (12 mg/kg for body weight(BW)<30 kg and 8 mg/kg for BW≥30 kg).

FIG. 16 model simulated TCZ Cmin for sJIA patients (162 mg Q2W for BW<30kg and 162 mg QW for BW≥30 kg).

FIG. 17 model simulated TCZ Cmin for sJIA patients (162 mg QW for BW<30kg and 162 mg QW for BW≥30 kg).

FIG. 18 model simulated TCZ Cmin for sJIA patients (162 mg Q10D forBW<30 kg and 162 QW for BW≥30 kg).

FIGS. 19A and 19B depict probability to reach pcJIA50 score (FIG. 19A)and pcJIA70 score (FIG. 19B) in study MRA318JP (8 mg/kg TCZ) indifferent body weight categories. Numbers on dotted lines indicate theprobability to reach pcJIA50 or pcJIA70 score.

FIGS. 20A and 20B depict simulated area under curve (AUC) vs body weight(BW) in Japanese Pediatric pcJIA patients (MRA318JP) after 6 months. TCZ8 mg/kg every 4 weeks in both body weight categories (n=19) (FIG. 20A);10 mg/kg or 8 mg/kg every 4 weeks in children with body weight <30 kgand ≥30 kg (n=19) (FIG. 20B). The full line represents a smoothed splinethrough the data. The dotted line (FIG. 20B) is a smoothed splineindicating the reference trend in the data without any change in mg/kgdose in children with a body weight lower than 30 kg.

FIGS. 21A and 21B depict PK profiles following IV administration every 4weeks (simulated for WA19977, FIG. 21A) and 162 mg SC administrationevery 2 weeks (simulated for patients from WA19977, FIG. 21B).

FIG. 22 is a schematic of subcutaneously administered anti-IL-6Rantibody (TCZ) in giant cell arteritis (GCA).

FIGS. 23A-23D show concentration-time profiles for TCZ (FIG. 23A),sIL-6R/TCZ complex (FIG. 23B), CRP (FIG. 23C), and ESR (FIG. 23D) fortwo body weight groups through week 16 in WA18221 study

FIGS. 24A-24D show concentration-time profiles for TCZ (FIG. 24A),sIL-6R (FIG. 24B), CRP (FIG. 24C) and ESR (FIG. 24D) for pcJIA patientsfrom the MRA318JP study.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS I. Definitions

Some abbreviations used herein: adverse event (AE), auto-injector (AI),area under curve (AUC), body weight (BW), corticosteroids (CS),C-reactive protein (CRP), every 10 days (Q10D), every week (QW), every 2weeks (Q2W), every 4 weeks (Q4W), giant cell arteritis (GCA),interleukin 6 (IL-6), interleukin 6 receptor (IL-6R), intravenous (IV),juvenile idiopathic arthritis (JIA), methotrexate (MTX), non-steroidalanti-inflammatory drugs (NSAIDs), pharmacodynamic (PD), pharmacokinetic(PK), polyarticular course juvenile idiopathic arthritis (pcJIA),pre-filled syringe (PFS), rheumatoid arthritis (RA), rheumatoid factor(RF), serious adverse event (SAE), soluble interleukin 6 receptor(sIL-6R), subcutaneous (SC), systemic juvenile idiopathic arthritis(sJIA), tocilizumab (TCZ), and water for injection (WFI).

Herein “human interleukin 6” (abbreviated as “IL-6”) is a cytokine alsoknown as B cell-stimulating factor 2 (BSF-2), or interferon beta-2(IFNB2), hybridoma growth factor, and CTL differentiation factor. IL-6was discovered as a differentiation factor contributing to activation ofB cells (Hirano et al., Nature 324: 73-76 (1986)), and was later foundto be a multifunction cytokine which influences the functioning of avariety of different cell types (Akira et al., Adv. in Immunology 54:1-78 (1993)). Naturally occurring human IL-6 variants are known andincluded in this definition. Human IL-6 amino acid sequence informationhas been disclosed, see for example, www.uniprot.org/uniprot/P05231.

For the purposes herein “human interleukin 6 receptor” (abbreviated as“IL-6R”) refers to the receptor which binds IL-6, including bothmembrane-bound IL-6R (mIL-6R) and soluble IL-6R (sIL-6R). IL-6R cancombine with interleukin 6 signal transducer glycoprotein 130 to form anactive receptor complex. Alternatively spliced transcript variantsencoding distinct isoforms of IL-6 have been reported and are includedin this definition. The amino acid sequence structure of human IL-6R andits extracellular domain have been described; see, for example, Yamasakiet al., Science, 241: 825 (1988).

A “neutralizing” anti-IL-6R antibody herein is one which binds to IL-6Rand is able to inhibit, to a measurable extent, the ability of IL-6 tobind to and/or active IL-6R. Toclizumab is an example of a neutralizinganti-IL-6R antibody.

“Tocilizumab” or “TCZ” is a recombinant humanized monoclonal antibodythat binds to human interleukin-6 receptor (IL-6R). It is an IgG1κ(gamma 1, kappa) antibody with a two heavy chains and two light chainsforming two antigen-binding sites. In a preferred embodiment, the lightchain and heavy chain amino acid sequences of Tocilizumab comprise SEQID NOs. 1 and 2, respectively (see FIGS. 7A-B).

A “native sequence” protein herein refers to a protein comprising theamino acid sequence of a protein found in nature, including naturallyoccurring variants of the protein. The term as used herein includes theprotein as isolated from a natural source thereof or as recombinantlyproduced.

The term “antibody” herein is used in the broadest sense andspecifically covers monoclonal antibodies, polyclonal antibodies,multispecific antibodies (e.g. bispecific antibodies) formed from atleast two intact antibodies, and antibody fragments so long as theyexhibit the desired biological activity.

“Antibody fragments” herein comprise a portion of an intact antibodywhich retains the ability to bind antigen. Examples of antibodyfragments include Fab, Fab′, F(ab′)₂, and Fv fragments; diabodies;linear antibodies; single-chain antibody molecules; and multispecificantibodies formed from antibody fragments.

The term “monoclonal antibody” as used herein refers to an antibodyobtained from a population of substantially homogeneous antibodies,i.e., the individual antibodies comprising the population are identicaland/or bind the same epitope, except for possible variants that mayarise during production of the monoclonal antibody, such variantsgenerally being present in minor amounts. In contrast to polyclonalantibody preparations that typically include different antibodiesdirected against different determinants (epitopes), each monoclonalantibody is directed against a single determinant on the antigen. Inaddition to their specificity, the monoclonal antibodies areadvantageous in that they are uncontaminated by other immunoglobulins.The modifier “monoclonal” indicates the character of the antibody asbeing obtained from a substantially homogeneous population ofantibodies, and is not to be construed as requiring production of theantibody by any particular method. For example, the monoclonalantibodies to be used in accordance with the present invention may bemade by the hybridoma method first described by Kohler et al., Nature,256:495 (1975), or may be made by recombinant DNA methods (see, e.g.,U.S. Pat. No. 4,816,567). The “monoclonal antibodies” may also beisolated from phage antibody libraries using the techniques described inClackson et al., Nature, 352:624-628 (1991) and Marks et al., J. Mol.Biol., 222:581-597 (1991), for example. Specific examples of monoclonalantibodies herein include chimeric antibodies, humanized antibodies, andhuman antibodies, including antigen-binding fragments thereof.

The monoclonal antibodies herein specifically include “chimeric”antibodies (immunoglobulins) in which a portion of the heavy and/orlight chain is identical with or homologous to corresponding sequencesin antibodies derived from a particular species or belonging to aparticular antibody class or subclass, while the remainder of thechain(s) is identical with or homologous to corresponding sequences inantibodies derived from another species or belonging to another antibodyclass or subclass, as well as fragments of such antibodies, so long asthey exhibit the desired biological activity (U.S. Pat. No. 4,816,567;Morrison et al., Proc. Natl. Acad. Sci. USA, 81:6851-6855 (1984)).Chimeric antibodies of interest herein include “primatized” antibodiescomprising variable domain antigen-binding sequences derived from anon-human primate (e.g. Old World Monkey, such as baboon, rhesus orcynomolgus monkey) and human constant region sequences (U.S. Pat. No.5,693,780).

“Humanized” forms of non-human (e.g., murine) antibodies are chimericantibodies that contain minimal sequence derived from non-humanimmunoglobulin. For the most part, humanized antibodies are humanimmunoglobulins (recipient antibody) in which residues from ahypervariable region of the recipient are replaced by residues from ahypervariable region of a non-human species (donor antibody) such asmouse, rat, rabbit or nonhuman primate having the desired specificity,affinity, and capacity. In some instances, framework region (FR)residues of the human immunoglobulin are replaced by correspondingnon-human residues. Furthermore, humanized antibodies may compriseresidues that are not found in the recipient antibody or in the donorantibody. These modifications are made to further refine antibodyperformance. In general, the humanized antibody will comprisesubstantially all of at least one, and typically two, variable domains,in which all or substantially all of the hypervariable regionscorrespond to those of a non-human immunoglobulin and all orsubstantially all of the FRs are those of a human immunoglobulinsequence, except for FR substitution(s) as noted above. The humanizedantibody optionally also will comprise at least a portion of animmunoglobulin constant region, typically that of a humanimmunoglobulin. For further details, see Jones et al., Nature321:522-525 (1986); Riechmann et al., Nature 332:323-329 (1988); andPresta, Curr. Op. Struct. Biol. 2:593-596 (1992). Humanized antibodiesherein specifically include “reshaped” IL-6R antibodies as described inU.S. Pat. No. 5,795,965, expressly incorporated herein by reference.

A “human antibody” herein is one comprising an amino acid sequencestructure that corresponds with the amino acid sequence structure of anantibody obtainable from a human B-cell, and includes antigen-bindingfragments of human antibodies. Such antibodies can be identified or madeby a variety of techniques, including, but not limited to: production bytransgenic animals (e.g., mice) that are capable, upon immunization, ofproducing human antibodies in the absence of endogenous immunoglobulinproduction (see, e.g., Jakobovits et al., Proc. Natl. Acad. Sci. USA,90:2551 (1993); Jakobovits et al., Nature, 362:255-258 (1993);Bruggermann et al., Year in Immuno., 7:33 (1993); and U.S. Pat. Nos.5,591,669, 5,589,369 and 5,545,807)); selection from phage displaylibraries expressing human antibodies or human antibody fragments (see,for example, McCafferty et al., Nature 348:552-553 (1990); Johnson etal., Current Opinion in Structural Biology 3:564-571 (1993); Clackson etal., Nature, 352:624-628 (1991); Marks et al., J. Mol. Biol. 222:581-597(1991); Griffith et al., EMBO J. 12:725-734 (1993); U.S. Pat. Nos.5,565,332 and 5,573,905); generation via in vitro activated B cells (seeU.S. Pat. Nos. 5,567,610 and 5,229,275); and isolation from humanantibody producing hybridomas.

A “multispecific antibody” herein is an antibody having bindingspecificities for at least two different epitopes. Exemplarymultispecific antibodies may bind to two different epitopes of IL-6R.Alternatively, an anti-IL-6R binding arm may be combined with an armthat binds to a triggering molecule on a leukocyte such as a T-cellreceptor molecule (e.g. CD2 or CD3), or Fc receptors for IgG (FcγR),such as FcγRI (CD64), FcγRII (CD32) and FcγRIII (CD16) so as to focuscellular defense mechanisms to the receptor. Multispecific antibodiescan be prepared as full-length antibodies or antibody fragments (e.g.F(ab′)₂ bispecific antibodies). Engineered antibodies with three or more(preferably four) functional antigen binding sites are also contemplated(see, e.g., US Appln No. US 2002/0004587 A1, Miller et al.).

Antibodies herein include “amino acid sequence variants” with alteredantigen-binding or biological activity. Examples of such amino acidalterations include antibodies with enhanced affinity for antigen (e.g.“affinity matured” antibodies), and antibodies with altered Fc region,if present, e.g. with altered (increased or diminished) antibodydependent cellular cytotoxicity (ADCC) and/or complement dependentcytotoxicity (CDC) (see, for example, WO 00/42072, Presta, L. and WO99/51642, Iduosogie et al.); and/or increased or diminished serumhalf-life (see, for example, WO00/42072, Presta, L.).

An “affinity matured variant” has one or more substituted hypervariableregion residues of a parent antibody (e.g. of a parent chimeric,humanized, or human antibody). Generally, the resulting variant(s)selected for further development will have improved antigen-bindingaffinity relative to the parent antibody from which they are generated.A convenient way for generating such substitutional variants involves“affinity maturation” using phage display. Briefly, severalhypervariable region sites (e.g. 6-7 sites) are mutated to generate allpossible amino substitutions at each site. The antibody variants thusgenerated are displayed in a monovalent fashion from filamentous phageparticles as fusions to the gene III product of M13 packaged within eachparticle. The phage-displayed variants are then screened for theirbiological activity (e.g. binding affinity). In order to identifycandidate hypervariable region sites for modification, alanine scanningmutagenesis can be performed to identify hypervariable region residuescontributing significantly to antigen binding. Alternatively, oradditionally, it may be beneficial to analyze a crystal structure of theantigen-antibody complex to identify contact points between the antibodyand human IL-2R. Such contact residues and neighboring residues arecandidates for substitution according to the techniques elaboratedherein. Once such variants are generated, the panel of variants issubjected to screening and antibodies with improved affinity may beselected for further development.

The antibody herein may be conjugated with a “heterologous molecule” forexample to increase half-life or stability or otherwise improve theantibody. For example, the antibody may be linked to one of a variety ofnon-proteinaceous polymers, e.g., polyethylene glycol (PEG),polypropylene glycol, polyoxyalkylenes, or copolymers of polyethyleneglycol and polypropylene glycol. Antibody fragments, such as Fab′,linked to one or more PEG molecules are an exemplary embodiment of theinvention.

The antibody herein may be a “glycosylation variant” such that anycarbohydrate attached to the Fc region, if present, is altered. Forexample, antibodies with a mature carbohydrate structure that lacksfucose attached to an Fc region of the antibody are described in US PatAppl No US 2003/0157108 (Presta, L.). See also US 2004/0093621 (KyowaHakko Kogyo Co., Ltd).

Antibodies with a bisecting N-acetylglucosamine (GlcNAc) in thecarbohydrate attached to an Fc region of the antibody are referenced inWO 2003/011878, Jean-Mairet et al. and U.S. Pat. No. 6,602,684, Umana etal. Antibodies with at least one galactose residue in theoligosaccharide attached to an Fc region of the antibody are reported inWO 1997/30087, Patel et al. See, also, WO 1998/58964 (Raju, S.) and WO1999/22764 (Raju, S.) concerning antibodies with altered carbohydrateattached to the Fc region thereof. See also US 2005/0123546 (Umana etal.) describing antibodies with modified glycosylation.

The term “hypervariable region” when used herein refers to the aminoacid residues of an antibody that are responsible for antigen binding.The hypervariable region comprises amino acid residues from a“complementarity determining region” or “CDR” (e.g. residues 24-34 (L1),50-56 (L2) and 89-97 (L3) in the light chain variable domain and 31-35(H1), 50-65 (H2) and 95-102 (H3) in the heavy chain variable domain;Kabat et al., Sequences of Proteins of Immunological Interest, 5th Ed.Public Health Service, National Institutes of Health, Bethesda, Md.(1991)) and/or those residues from a “hypervariable loop” (e.g. residues26-32 (L1), 50-52 (L2) and 91-96 (L3) in the light chain variable domainand 26-32 (H1), 53-55 (H2) and 96-101 (H3) in the heavy chain variabledomain; Chothia and Lesk J. Mol. Biol. 196:901-917 (1987)). “Framework”or “FR” residues are those variable domain residues other than thehypervariable region residues as herein defined. The hypervariableregions of Tocilizumab comprise:

L1—Arg Ala Ser Gln Asp Ile Ser Ser Tyr Leu Asn (SEQ ID NO: 3); L2—TyrThr Ser Arg Leu His Ser (SEQ ID NO: 4); L3—Gln Gln Gly Asn Thr Leu ProTyr Thr (SEQ ID NO:5); H1—Ser Asp His Ala Trp Ser (SEQ ID NO:6); H2—TyrIle Ser Tyr Ser Gly Ile Thr Thr Tyr Asn Pro Ser Leu Lys Ser (SEQ IDNO:7); and H3—Ser Leu Ala Arg Thr Thr Ala Met Asp Tyr (SEQ ID NO:8).

In one embodiment herein, the IL-6R antibody comprises the hypervariableregions of Tocilizumab.

A “full length antibody” is one which comprises an antigen-bindingvariable region as well as a light chain constant domain (CL) and heavychain constant domains, CH1, CH2 and CH3. The constant domains may benative sequence constant domains (e.g. human native sequence constantdomains) or amino acid sequence variants thereof. Preferably, the fulllength antibody has one or more effector functions. Tocilizumab is anexample of a full-length antibody.

A “naked antibody” is an antibody (as herein defined) that is notconjugated to a heterologous molecule, such as a cytotoxic moiety,polymer, or radiolabel.

Antibody “effector functions” refer to those biological activitiesattributable to the Fc region (a native sequence Fc region or amino acidsequence variant Fc region) of an antibody. Examples of antibodyeffector functions include C1q binding, complement dependentcytotoxicity (CDC), Fc receptor binding, antibody-dependentcell-mediated cytotoxicity (ADCC), etc.

Depending on the amino acid sequence of the constant domain of theirheavy chains, full length antibodies can be assigned to different“classes”. There are five major classes of full length antibodies: IgA,IgD, IgE, IgG, and IgM, and several of these may be further divided into“subclasses” (isotypes), e.g., IgG1, IgG2, IgG3, IgG4, IgA, and IgA2.The heavy-chain constant domains that correspond to the differentclasses of antibodies are called alpha, delta, epsilon, gamma, and mu,respectively. The subunit structures and three-dimensionalconfigurations of different classes of immunoglobulins are well known.

The term “recombinant antibody”, as used herein, refers to an antibody(e.g. a chimeric, humanized, or human antibody or antigen-bindingfragment thereof) that is expressed by a recombinant host cellcomprising nucleic acid encoding the antibody. Examples of “host cells”for producing recombinant antibodies include: (1) mammalian cells, forexample, Chinese Hamster Ovary (CHO), COS, myeloma cells (including Y0and NS0 cells), baby hamster kidney (BHK), Hela and Vero cells; (2)insect cells, for example, sf9, sf21 and Tn5; (3) plant cells, forexample plants belonging to the genus Nicotiana (e.g. Nicotianatabacum); (4) yeast cells, for example, those belonging to the genusSaccharomyces (e.g. Saccharomyces cerevisiae) or the genus Aspergillus(e.g. Aspergillus niger); (5) bacterial cells, for example Escherichiacoli cells or Bacillus subtilis cells, etc.

As used herein, “specifically binding” or “binds specifically to” refersto an antibody selectively or preferentially binding to IL-6R antigen.Preferably the binding affinity for antigen is of Kd value of 10⁻⁹ mol/lor lower (e.g. 10⁻¹⁰ mol/l), preferably with a Kd value of 10⁻¹⁰ mol/lor lower (e.g. 10⁻¹² mol/l). The binding affinity is determined with astandard binding assay, such as surface plasmon resonance technique(BIACORE®).

For the purposes herein, the term “IL-6-mediated disorder” refers to adisease or disorder in which activation of IL-6R by IL-6 results in thedisorder and/or treatment with an anti-IL-6R antibody can be used totreat the disease or disorder. Examples of such disorders include:autoimmune diseases, osteoporosis, neoplasia, aging, rheumatoidarthritis (RA), juvenile idiopathic arthritis (JIA) (including systemicJIA and polyarticular course JIA), psoriatic arthritis, Castleman'sdisease, Crohn's disease, multiple myeloma, polymyalgia rheumatica,glomerulonephritis, plasmacytoma or plasmacytosis, myeloma (includingmultiple myeloma), hyperimmunoglobulinemia, anemia, nephritis (such asmesangium proliferative nephritis), cachexia (including cancerouscachexia), tumors, T cell mediated disease (e.g. uveitis, chronicthyroiditis, delayed hypersensitivity, contact dermatitis, or atopicdermatitis), lupus (including lupus nephritis and systemic lupuserythmatosus), inflammatory bowel disease (including Crohn's disease andulcerative colitis), pancreatitis, psoriasis, osteoarthritis,adult-onset Still's disease, mesothelioma, vasculitis, islettransplantation (e.g. pancreatic islet transplantation), myocardialinfarction (heart failure, ischemia-induced severe arrhythmia), hearttransplantation, prostate cancer, choroidal neovascularization (e.g.age-related macular degeneration, idiopathic choroidalneovascularization, cyopic choroidal neovascularization, idiopathicchoroidal neovascularization), muscle atrophy, chronic rejection, ocularinflammatory disease (e.g. panuveitis, anterior aveitis, intermediateuveitis, scleritis, keratitis, orbital inflammation, optic neuritis, dryeye, diabetic retinopathy, proliferative vitreoretinopathy,postoperative inflammation), graft versus host disease (GVHD), fibroticdisorders (such as systemic sclerosis), giant cell arteritis (GCA), andTakayasu's arteritis (TA), arteritis nodosa, ankylosing spondylitis,etc.

In one embodiment, the IL-6-mediated disorder is rheumatoid arthritis.

In one embodiment, the IL-6 mediated disorder is juvenile idiopathicarthritis (JIA).

In one embodiment, the IL-6 mediated disorder is systemic JIA (sJIA).

In one embodiment, the IL-6 mediated disorder is polyarticular courseJIA (pcJIA).

In one embodiment, the IL-6 mediated disorder is systemic sclerosis.

In one embodiment, the IL-6 mediated disorder is giant cell arteritis(GCA).

In one embodiment, the IL-6 mediated disorder is psoriatic arthritis.

In one embodiment, the IL-6 mediated disorder is uveitis.

As used herein, “rheumatoid arthritis” (abbreviated as “RA”) refers tois a chronic, systemic inflammatory disorder that may affect manytissues and organs, but principally attacks synovial joints. RAdiagnosed according to the RA must be diagnosed according to the 1987 or2000 revised American College of Rheumatology (ACR; formerly AmericanRheumatism Association) criteria for the classification of rheumatoidarthritis, or any similar criteria. Physiological indicators of RAinclude, symmetric joint swelling which is characteristic though notinvariable in rheumatoid arthritis. Fusiform swelling of the proximalinterphalangeal (PIP) joints of the hands as well as metacarpophalangeal(MCP), wrists, elbows, knees, ankles and metatarsophalangeal (MTP)joints are commonly affected and swelling is easily detected. Pain onpassive motion is the most sensitive test for joint inflammation, andinflammation and structural deformity often limits the range of motionfor the affected joint. Typical visible changes include ulnar deviationof the fingers at the MCP joints, hyperextension or hyperflexion of theMCP and PIP joints, flexion contractures of the elbows, and subluxationof the carpal bones and toes.

A patient with “active rheumatoid arthritis” means a patient with activeand not latent symptoms of rheumatoid arthritis. In one embodiment, suchpatient has moderate-to-severe active RA of ≥6 months disease durationat time of baseline visit. In one embodiment, such patients will have:(1) swollen joint count (SJC)≥4 (66 joint count), (2) tender joint count(TJC)≥4 (68 joint count), and/or C-reactive protein (CRP)≥upper limit ofnormal (ULN) at screening visit.

Examples of “disease-modifying anti-rheumatic drugs” or “DMARDs” includehydroxycloroquine, sulfasalazine, methotrexate, leflunomide,azathioprine, D-penicillamine, gold salts (oral), gold salts(intramuscular), minocycline, cyclosporine including cyclosporine A andtopical cyclosporine, staphylococcal protein A, and TNF-inhibitors (seebelow), including salts, variants, and derivatives thereof, etc.Exemplary DMARDs herein are non-biological DMARDs, including, inparticular, azathioprine, chloroquine, hydroxychloroquine, leflunomide,methotrexate and sulfasalazine, with methotrexate being the DMARDaccording to one embodiment of the invention.

For the purposes herein, “tumor necrosis factor” (abbreviated “TNF”)refers to a human TNF-alpha molecule comprising the amino acid sequenceas described in Pennica et al., Nature, 312:721 (1984) or Aggarwal etal., JBC, 260:2345 (1985).

A “TNF-inhibitor” herein is an agent that inhibits, to some extent, abiological function of TNF-alpha, generally through binding to TNF-alphaand neutralizing its activity. Examples of TNF inhibitors specificallycontemplated herein are etanercept (ENBREL®), infliximab (REMICADE®),and adalimumab (HUMIRA®), certolizumab pegol (CIMZIA®), and golimumab(SIMPONI®).

The subject who is a “DMARD inadequate responder” is one who hasexperienced an inadequate response to previous or current treatment withone or more DMARDs (including one or more TNF inhibitors) because oftoxicity or inadequate efficacy.

The subject who is a “TNF inhibitor inadequate responder” hasexperienced an inadequate response to previous or current treatment withone or more TNF inhibitors because of toxicity or inadequate efficacy.In one embodiment, such patient has received, for example, etanerceptfor ≥3 months at 25 mg twice a week or at least 4 infusions ofinfliximab at ≥3 mg/kg but had an inadequate response thereto.

A “methotrexate inadequate responder” is a patient who has experiencedan inadequate response to previous or current treatment withmethotrexate because of toxicity or inadequate efficacy. In oneembodiment, the patient has been on methotrexate (10-25 mg/week) for atleast 12 weeks and still has active disease.

A “fixed dose” herein refers to a dosage of a drug, such as ananti-IL-6R antibody which is administered without regard to thepatient's weight or body surface area (BSA), i.e. it is not administeredas either a mg/kg or mg/m² dose.

“Treatment” of a subject herein refers to both therapeutic treatment andprophylactic or preventative measures.

The expression “effective amount” refers to an amount of the antibodythat is effective for treating the IL-6 disorder. Where the disorder isRA, such effective amount can result in any one or more of reducing thesigns or symptoms of RA (e.g. achieving ACR20, ACR50, or ACR70 responseat week 24 and/or week 48), reducing disease activity (e.g. DiseaseActivity Score, DAS20), ACR-hybrid, slowing the progression ofstructural joint damage, improving physical function, etc. In oneembodiment, such clinical response is comparable to that achieved withintravenously administered anti-IL-6R antibody.

The expression “inhibiting progression of structural joint damage” in aRA patient refers to preventing or slowing structural joint damagecaused by RA, for example based on eroded joint count and/or jointdamage score. Methods for measuring progression of structural jointdamage are known to the skilled person, and include, without limitationGenant-modified Total Sharp Score (TSS), erosion score (ES), and/orjoint space narrowing (JSN) score.

The term “immunosuppressive agent” as used herein for adjunct therapyrefers to substances that act to suppress or mask the immune system ofthe mammal being treated herein. This would include substances thatsuppress cytokine production, down-regulate or suppress self-antigenexpression, or mask the MHC antigens. Examples of such agents include2-amino-6-aryl-5-substituted pyrimidines (see U.S. Pat. No. 4,665,077);non-steroidal anti-inflammatory drugs (NSAIDs); ganciclovir, tacrolimus,glucocorticoids such as cortisol or aldosterone, anti-inflammatoryagents such as a cyclooxygenase inhibitor, a 5-lipoxygenase inhibitor,or a leukotriene receptor antagonist; purine antagonists such asazathioprine or mycophenolate mofetil (MMF); alkylating agents such ascyclophosphamide; bromocryptine; danazol; dapsone; glutaraldehyde (whichmasks the MHC antigens, as described in U.S. Pat. No. 4,120,649);anti-idiotypic antibodies for MHC antigens and MHC fragments;cyclosporin A; steroids such as corticosteroids or glucocorticosteroidsor glucocorticoid analogs, e.g., prednisone, methylprednisolone,including SOLU-MEDROL® methylprednisolone sodium succinate, anddexamethasone; dihydrofolate reductase inhibitors such as methotrexate(oral or subcutaneous); anti-malarial agents such as chloroquine andhydroxychloroquine; sulfasalazine; leflunomide; cytokine antagonistssuch as cytokine antibodies or cytokine receptor antibodies includinganti-interferon-alpha, -beta, or -gamma antibodies, anti-tumor necrosisfactor (TNF)-alpha antibodies (infliximab (REMICADE®) or adalimumab),anti-TNF-alpha immunoadhesin (etanercept), anti-TNF-beta antibodies,anti-interleukin-2 (IL-2) antibodies and anti-IL-2 receptor antibodies,and anti-interleukin-6 (IL-6) receptor antibodies and antagonists;anti-LFA-1 antibodies, including anti-CD11a and anti-CD18 antibodies;anti-L3T4 antibodies; heterologous anti-lymphocyte globulin; pan-Tantibodies, preferably anti-CD3 or anti-CD4/CD4a antibodies; solublepeptide containing a LFA-3 binding domain (WO 90/08187 published Jul.26, 1990); streptokinase; transforming growth factor-beta (TGF-beta);streptodornase; RNA or DNA from the host; FK506; RS-61443; chlorambucil;deoxyspergualin; rapamycin; T-cell receptor (Cohen et al., U.S. Pat. No.5,114,721); T-cell receptor fragments (Offner et al., Science, 251:430-432 (1991); WO 90/11294; Ianeway, Nature, 341: 482 (1989); and WO91/01133); BAFF antagonists such as BAFF antibodies and BR3 antibodiesand zTNF4 antagonists (for review, see Mackay and Mackay, TrendsImmunol., 23:113-5 (2002)); biologic agents that interfere with T cellhelper signals, such as anti-CD40 receptor or anti-CD40 ligand (CD154),including blocking antibodies to CD40-CD40 ligand (e.g., Durie et al.,Science, 261: 1328-30 (1993); Mohan et al., J. Immunol., 154: 1470-80(1995)) and CTLA4-Ig (Finck et al., Science, 265: 1225-7 (1994)); andT-cell receptor antibodies (EP 340,109) such as T10B9. Someimmunosuppressive agents herein are also DMARDs, such as methotrexate.Examples of immunosuppressive agents herein include cyclophosphamide,chlorambucil, azathioprine, leflunomide, MMF, or methotrexate.

The “CD20” antigen, or “CD20,” is an about 35-kDa, non-glycosylatedphosphoprotein found on the surface of greater than 90% of B cells fromperipheral blood or lymphoid organs. CD20 is present on both normal Bcells as well as malignant B cells, but is not expressed on stem cells.Other names for CD20 in the literature include “B-lymphocyte-restrictedantigen” and “Bp35”. The CD20 antigen is described in Clark et al.,Proc. Natl. Acad. Sci. (USA) 82:1766 (1985), for example.

Examples of CD20 antibodies include: “C2B8,” which is now called“rituximab” (“RITUXAN®/MABTHERA®”) (U.S. Pat. No. 5,736,137); theyttrium-[90]-labelled 2B8 murine antibody designated “Y2B8” or“Ibritumomab Tiuxetan” (ZEVALIN®) commercially available from BiogenIdec, Inc. (e.g., U.S. Pat. No. 5,736,137; 2B8 deposited with ATCC underaccession no. HB11388 on Jun. 22, 1993); murine IgG2a “B1,” also called“Tositumomab,” optionally labelled with ¹³¹I to generate the “131I-B1”or “iodine I131 tositumomab” antibody (BEXXAR™) commercially availablefrom Corixa (see, also, e.g., U.S. Pat. No. 5,595,721); murinemonoclonal antibody “1F5” (e.g., Press et al. Blood 69(2):584-591 (1987)and variants thereof including “framework patched” or humanized 1F5(e.g., WO 2003/002607, Leung, S.; ATCC deposit HB-96450); murine 2H7 andchimeric 2H7 antibody (e.g., U.S. Pat. No. 5,677,180); a humanized 2H7(e.g., WO 2004/056312 (Lowman et al.) and as set forth below);HUMAX-CD20™ fully human, high-affinity antibody targeted at the CD20molecule in the cell membrane of B-cells (Genmab, Denmark; see, forexample, Glennie and van de Winkel, Drug Discovery Today 8: 503-510(2003) and Cragg et al., Blood 101: 1045-1052 (2003)); the humanmonoclonal antibodies set forth in WO 2004/035607 and WO 2005/103081(Teeling et al., GenMab/Medarex); the antibodies having complexN-glycoside-linked sugar chains bound to the Fc region described in US2004/0093621 (Shitara et al.); monoclonal antibodies and antigen-bindingfragments binding to CD20 (e.g., WO 2005/000901, Tedder et al.) such asHB20-3, HB20-4, HB20-25, and MB20-11; single-chain proteins binding toCD20 (e.g., US 2005/0186216 (Ledbetter and Hayden-Ledbetter); US2005/0202534 (Hayden-Ledbetter and Ledbetter); US 2005/0202028(Hayden-Ledbetter and Ledbetter); US 2005/0202023 (Hayden-Ledbetter andLedbetter, Trubion Pharm Inc.); CD20-binding molecules such as the AMEseries of antibodies, e.g., AME-33™ antibodies as set forth, forexample, in WO 2004/103404 and US 2005/0025764 (Watkins et al., AppliedMolecular Evolution, Inc.) and the CD20 antibodies with Fc mutations asset forth, for example, in WO 2005/070963 (Allan et al., AppliedMolecular Evolution, Inc.); CD20-binding molecules such as thosedescribed in WO 2005/016969 and US 2005/0069545 (Can et al.); bispecificantibodies as set forth, for example, in WO 2005/014618 (Chang et al.);humanized LL2 monoclonal antibodies as described, for example, in US2005/0106108 (Leung and Hansen; Immunomedics); chimeric or humanizedB-Ly1 antibodies to CD20 as described, for example, in WO2005/044859 andUS 2005/0123546 (Umana et al.; GlycArt Biotechnology AG); A20 antibodyor variants thereof such as chimeric or humanized A20 antibody (cA20,hA20, respectively) and IMMUN-106 (e.g., US 2003/0219433, Immunomedics);and monoclonal antibodies L27, G28-2, 93-1B3, B-C1 or NU-B2 availablefrom the International Leukocyte Typing Workshop (e.g., Valentine etal., In: Leukocyte Typing III (McMichael, Ed., p. 440, Oxford UniversityPress (1987)). The preferred CD20 antibodies herein are chimeric,humanized, or human CD20 antibodies, more preferably rituximab, ahumanized 2H7, chimeric or humanized A20 antibody (Immunomedics),HUMAX-CD20™ human CD20 antibody (Genmab), and immunoglobulins/proteinsbinding to CD20 (Trubion Pharm Inc.).

The terms “rituximab” or “RITUXAN®” herein refer to the geneticallyengineered chimeric murine/human monoclonal antibody directed againstthe CD20 antigen and designated “C2B8” in U.S. Pat. No. 7,381,560(Anderson et. al.), including fragments thereof which retain the abilityto bind CD20.

Examples of “non-steroidal anti-inflammatory drugs” or “NSAIDs” includeaspirin, acetylsalicylic acid, ibuprofen, flurbiprofen, naproxen,indomethacin, sulindac, tolmetin, phenylbutazone, diclofenac,ketoprofen, benorylate, mefenamic acid, methotrexate, fenbufen,azapropazone; COX-2 inhibitors such as celecoxib (CELEBREX®;4-(5-(4-methylphenyl)-3-(trifluoromethyl)-1H-pyrazol-1-yl)benzenesulfonamide, valdecoxib (BEXTRA®), meloxicam (MOBIC®), GR 253035(Glaxo Wellcome); and MK966 (Merck Sharp & Dohme), including salts andderivatives thereof, etc. Preferably, they are aspirin, naproxen,ibuprofen, indomethacin, or tolmetin.

“Corticosteroid” refers to any one of several synthetic or naturallyoccurring substances with the general chemical structure of steroidsthat mimic or augment the effects of the naturally occurringcorticosteroids. Examples of synthetic corticosteroids includeprednisone, prednisolone (including methylprednisolone, such asSOLU-MEDROL® methylprednisolone sodium succinate), dexamethasone ordexamethasone triamcinolone, hydrocortisone, and betamethasone. Thepreferred corticosteroids herein are prednisone, methylprednisolone,hydrocortisone, or dexamethasone.

A “medicament” is an active drug to treat the joint damage or itssymptoms or side effects.

The term “pharmaceutical formulation” refers to a preparation which isin such form as to permit the biological activity of the activeingredient or ingredients to be effective, and which contains noadditional components which are unacceptably toxic to a subject to whichthe formulation would be administered. Such formulations are sterile.

A “sterile” formulation is aseptic or free from all livingmicroorganisms and their spores.

A “stable” formulation is one in which all the protein thereinessentially retain their physical stability and/or chemical stabilityand/or biological activity upon storage at the intended storagetemperature, e.g. 2-8° C. Preferably, the formulation essentiallyretains its physical and chemical stability, as well as its biologicalactivity upon storage. The storage period is generally selected based onthe intended shelf-life of the formulation. Furthermore, the formulationis preferably stable following freezing (to, e.g., −20° C.) and thawingof the formulation, for example following 1 or more cycles of freezingand thawing. Various analytical techniques for measuring proteinstability are available in the art and are reviewed in Peptide andProtein Drug Delivery, 247-301, Vincent Lee Ed., Marcel Dekker, Inc.,New York, N.Y., Pubs. (1991) and Jones, A. Adv. Drug Delivery Rev. 10:29-90 (1993), for example. Stability can be measured at a selectedtemperature for a selected time period. Stability can be evaluatedqualitatively and/or quantitatively in a variety of different ways,including evaluation of aggregate formation (for example using sizeexclusion chromatography, by measuring turbidity, and/or by visualinspection); by assessing charge heterogeneity using cation exchangechromatography or capillary zone electrophoresis; SDS-PAGE analysis tocompare reduced and intact antibody; evaluating biological activity orantigen binding function of the antibody; etc.

A “stabilizer” herein is an excipient, or mixture of two or moreexcipients, which stabilizes a pharmaceutical formulation. For example,the stabilizer can prevent instability due to freezing-thawing or otherthermal-induced destabilization of the formulation. Exemplary excipientsherein include surfactants, and amino acids, such as arginine ormethionine (including derivatives thereof).

The term “surfactant” as used herein denotes a pharmaceuticallyacceptable surface-active agent. In the formulation of the invention,the amount of surfactant is described a percentage expressed inweight/volume. The most commonly used weight/volume unit is mg/mL.Suitable examples of pharmaceutically acceptable surfactants includepolyoxyethylene-sorbitan fatty acid esters, polyethylene-polypropyleneglycols, polyoxyethylene-stearates, polyoxyethylene alkyl ethers, e.g.polyoxyethylene monolauryl ether, alkylphenylpolyoxy-ethylene ethers(Triton-X), polyoxyethylene-polyoxypropylene copolymer (Poloxamer,Pluronic), and sodium dodecyl sulphate (SDS). Most suitablepolyoxyethylenesorbitan-fatty acid esters are polysorbate 20 (sold underthe trademark TWEEN 20®) and polysorbate 80 (sold under the trademarkTWEEN 80®). Most suitable polyethylene-polypropylene copolymers arethose sold under the names PLURONIC® F68 or POLOXAMER 188®. Preferredpolyoxyethylene-stearates are those sold under the trademark MYRJ™. Mostsuitable polyoxy-ethylene alkyl ethers are those sold under thetrademark BRIJ™. Most suitable alkylphenolpoly-oxyethylene ethers aresold under the trade name TRITON-X®.

The term “buffer” as used herein denotes a pharmaceutically acceptablebuffer which resists changes in pH by the action of its acid/baseconjugate components. Optionally, the pH of the formulation is in therange from 5 to 7, e.g. from 5.5 to 6.5, most preferably about pH 6, andthe buffer employed achieves such desired pH for the formulation.Suitable pharmaceutically acceptable buffers according to the inventioncomprise but are not limited to histidine-buffers, citrate-buffers,gluconate-buffers, succinate-buffers, acetate-buffers glycylglycine andother organic acid buffers, and phosphate-buffers. Preferred bufferscomprise L-histidine or mixtures of L-histidine with L-histidinehydrochloride with isotonicity agents and potentially pH adjustment withan acid or a base known in the art. Most preferred is histidine (e.g.L-histidine).

By “isotonic” is meant that the formulation of interest has essentiallythe same osmotic pressure as human blood. Isotonic formulations willgenerally have an osmotic pressure from about 250 to 350 mOsm.Isotonicity can be measured using a vapor pressure or ice-freezing typeosmometer, for example.

A “liquid formulation” or “aqueous formulation” according to theinvention denotes a formulation which is liquid at a temperature of atleast about 2 to about 8° C.

The term “lyophilized formulation” denotes a formulation which is driedby freezing the formulation and subsequently subliming the ice from thefrozen content by any freeze-drying methods known in the art, forexample commercially available freeze-drying devices. Such formulationscan be reconstituted in a suitable diluent, such as water, sterile waterfor injection, saline solution etc, to form a reconstituted liquidformulation suitable for administration to a subject.

“Hyaluronan” (abbreviated “HA” and also called “hyaluronic acid” or“hyaluronate”) is an anionic, nonsulfated glycosaminoglycan distributedwidely throughout connective, epithelial, and neural tissues.

“Hyaluronidases” are enzymes that degrade hyaluronic acid. In humans,there are six associated genes, including HYALPI (pseudogene), HYAL1,HYAL2, HYAL3, HYAL4, and PH20/SPAM1. The term herein includes“acid-active” enzymes (such as HYAL1), and “neutral-active” enzymes(such as PH20). It also includes enzymes with or without aglycosylphosphtidy inositol anchor; preferably the hyaluronidase issoluble or lacks an anchor. Hyaluronidases can be included in apharmaceutical formulation in order to: facilitate administration of thetherapeutic drug into the hypodermis, reduce the viscosity of theinterstitum, allow larger volumes to be administered SC, and/or increaseabsorption and dispersion of another injected drug. The hyaluronidaseenzyme in a pharmaceutical formulation herein is characterized by havingno adverse effect on the molecular integrity of the anti-IL-6R antibodyin the formulation, and while it modifies the delivery of the anti-IL-6Rantibody to the systemic circulation it does not possess any propertiesthat could provide or contribute to the therapeutic effects ofsystemically absorbed anti-IL-6R antibody. See, also, WO 2004/078140,WO2006/091871 and U.S. Pat. No. 7,767,429 regarding hyaluronidasesaccording to the present invention. Hyaluronidase products approved inEU countries include HYALASE®. Hyaluronidase products of animal originapproved in the US include VITRASE™, HYDRASE™, and AMPHADASE™. Thepreferred hyaluronidase herein is recombinant human PH20.

“Recombinant human PH20” (abbreviated “rHuPH20”) refers to a soluble,neutral pH-active enzyme comprising a truncated human PH20 amino acidsequence. It can be synthesized with a 35 amino acid signal peptide thatis removed from the N-terminus during the process of secretion so as toprovide an N-terminal amino acid sequence found in some bovinehyaluronidase preparations. Preferably, rHuPH20 herein comprises theamino acid sequence available under CAS Registry No. 757971-58-7 or asdisclosed in U.S. Pat. No. 7,767,429, expressly incorporated herein byreference, and has an approximate molecular weight of 61 kDa. See, also,Frost, G. I., “Recombinant human hyaluronidase (rHuPH20): an enablingplatform for subcutaneous drug and fluid administration”, Expert Opinionon Drug Delivery 4: 427-440 (2007)). The term herein includes rHuPH20(HYLENEX®) commercially available from Halozyme Therapeutics Inc.

A “subcutaneous administration device” refers to a device, such assyringe, injection device, infusion pump, injector pen, needlelessdevice, patch delivery system, etc, which is adapted or designed toadminister a drug or pharmaceutical formulation by the subcutaneousroute. In one embodiment, the device administers about 0.9 mL, 1.8 mL,or 3.6 mL of a pharmaceutical formulation.

A “package insert” is used to refer to instructions customarily includedin commercial packages of therapeutic products, that contain informationabout the indications, usage, dosage, administration, contraindications,other therapeutic products to be combined with the packaged product,and/or warnings concerning the use of such therapeutic products, etc.

Herein, a “fibrotic disease” is one involving the formation of excessfibrous connective tissue in an organ and/or tissue. Examples offibrotic diseases herein include: systemic sclerosis (scleroderma),keloids, hypertrophic scars, burn scars, liver fibrosis, livercirrhosis, pulmonary hypertension, pulmonary fibrosis (includingidiopathic pulmonary fibrosis, IPF), cardiac fibrosis, kidney fibrosis,hepatic fibrosis, etc. In one embodiment, the fibrotic disease issystemic sclerosis.

“Systemic sclerosis” (SSc) or “scleroderma” is a complex andheterogeneous disease with skin and tissue fibrosis, vascularalterations, and autoantibodies against various cellular antigens beingamongst its principal features. The clinical manifestations of systemicsclerosis can range from limited skin involvement to severe internalorgan dysfunction. Internal visceral organ pathology is a major factorcontributing to the morbidity of this disease, with the kidneys,esophagus, heart, and lungs being the most frequently involved. Thereare two major subgroups in the commonly accepted classification of SSc:limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc).Gabrielli et al. Mechanisms of disease. Scleroderma. N Engl J Med360:1989-2003 (2009).

In one embodiment, the patient with systemic sclerosis has beenclassified according to the American College of Rheumatology (formerly,the American Rheumatism Association) criteria for the classification ofsystemic scleroderma based on:

major criterion: proximal diffuse (truncal) sclerosis (skin tightness,thickening, and non-pitting induration); and

minor criteria: (1) sclerodactyly (only fingers and/or toes), (2)digital pitting scars or loss of substance of the digital finger pads(pulp loss), and (3) bilateral basilar pulmonary fibrosis, wherein apatient with systemic sclerosis should fulfill the major criterion ortwo of the three minor criteria. See Subcommittee for SclerodermaCriteria of the American Rheumatism Association, Diagnostic andTherapeutic Criteria Committee. Preliminary criteria for theclassification of systemic sclerosis (scleroderma). Arthritis Rheum23:581-90 (1980).

II. Production of Anti-IL-6R Antibodies

The methods and articles of manufacture of the present invention use, orincorporate, an antibody that binds to human IL-6R. IL-6R antigen to beused for production of, or screening for, antibodies may be, e.g., asoluble form of IL-6R or a portion thereof (e.g. the extracellulardomain), containing the desired epitope. Alternatively, or additionally,cells expressing IL-6R at their cell surface can be used to generate, orscreen for, antibodies. Other forms of IL-6R useful for generatingantibodies will be apparent to those skilled in the art.

In one embodiment, the antibody is an antibody fragment, various suchfragments being disclosed above.

In another embodiment, the antibody is an intact or full-lengthantibody. Depending on the amino acid sequence of the constant domain oftheir heavy chains, intact antibodies can be assigned to differentclasses. There are five major classes of intact antibodies: IgA, IgD,IgE, IgG, and IgM, and several of these may be further divided intosubclasses (isotypes), e.g., IgG1, IgG2, IgG3, IgG4, IgA, and IgA2. Theheavy chain constant domains that correspond to the different classes ofantibodies are called α, δ, ε, γ, and μ, respectively. The subunitstructures and three-dimensional configurations of different classes ofimmunoglobulins are well known. In a preferred embodiment, theanti-IL-6R antibody is an IgG1 or IgM antibody.

Techniques for generating antibodies are known and examples providedabove in the definitions section of this document. In a preferredembodiment, the antibody is a chimeric, humanized, or human antibody orantigen-binding fragment thereof. Preferably the antibody is a humanizedfull-length antibody.

Various techniques are available for determining binding of the antibodyto the IL-6R. One such assay is an enzyme linked immunosorbent assay(ELISA) for confirming an ability to bind to human IL-6R. See, forexample, U.S. Pat. No. 5,795,965. According to this assay, plates coatedwith IL-6R (e.g. recombinant sIL-6R) are incubated with a samplecomprising the anti-IL-6R antibody and binding of the antibody to thesIL-6R is determined.

Preferably, the anti-IL-6R antibody is neutralizes IL-6 activity, e.g.by inhibiting binding of IL-6 to IL-6R. An exemplary method forevaluating such inhibition is disclosed in U.S. Pat. Nos. 5,670,373, and5,795,965, for example. According to this method, the ability of theantibody to compete with IL-6 to IL-6R is evaluated. For example, aplate is coated with IL-6R (e.g. recombinant sIL-6R), a samplecomprising the anti-IL-6R antibody with labeled IL-6 is added, and theability of the antibody to block binding of the labeled IL-6 to theIL-6R is measured. See, U.S. Pat. No. 5,795,965. Alternatively, oradditionally, identification of binding of IL-6 to membrane-bound IL-6Ris carried out according to the method of Taga et al. J Exp. Med., 166:967 (1987). An assay for confirming neutralizing activity using theIL-6-dependent human T-cell leukemia line KT3 is also available, see,U.S. Pat. No. 5,670,373, and Shimizu et al. Blood 72: 1826 (1988).

Non-limiting examples of anti-IL-6R antibodies herein include PM-1antibody (Hirata et al., J. Immunol. 143:2900-2906 (1989), AUK12-20,AUK64-7, and AUK146-15 antibody (U.S. Pat. No. 5,795,965), as well ashumanized variants thereof, including, for example, tocilizumab. See,U.S. Pat. No. 5,795,965. Preferred examples of the reshaped humanantibodies used in the present invention include humanized or reshapedanti-interleukin (IL-6) receptor antibodies (hPM-1 or MRA) (see U.S.Pat. No. 5,795,965).

The antibody herein is preferably recombinantly produced in a host celltransformed with nucleic acid sequences encoding its heavy and lightchains (e.g. where the host cell has been transformed by one or morevectors with the nucleic acid therein). The preferred host cell is amammalian cell, most preferably a Chinese Hamster Ovary (CHO) cells.

III. Pharmaceutical Formulations

Therapeutic formulations of the antibodies used in accordance with thepresent invention are prepared for storage by mixing an antibody havingthe desired degree of purity with optional pharmaceutically acceptablecarriers, excipients or stabilizers (Remington's Pharmaceutical Sciences16th edition, Osol, A. Ed. (1980)), in the form of lyophilizedformulations or aqueous solutions. Acceptable carriers, excipients, orstabilizers are nontoxic to recipients at the dosages and concentrationsemployed, and include buffers such as phosphate, citrate, and otherorganic acids; antioxidants including ascorbic acid and methionine;preservatives (such as octadecyldimethylbenzyl ammonium chloride;hexamethonium chloride; benzalkonium chloride, benzethonium chloride;phenol, butyl or benzyl alcohol; alkyl parabens such as methyl or propylparaben; catechol; resorcinol; cyclohexanol; 3-pentanol; and m-cresol);low molecular weight (less than about 10 residues) polypeptides;proteins, such as serum albumin, gelatin, or immunoglobulins;hydrophilic polymers such as polyvinylpyrrolidone; amino acids such asglycine, glutamine, asparagine, histidine, arginine, or lysine;monosaccharides, disaccharides, and other carbohydrates includingglucose, mannose, or dextrins; chelating agents such as EDTA; sugarssuch as sucrose, mannitol, trehalose or sorbitol; salt-formingcounter-ions such as sodium; metal complexes (e.g. Zn-proteincomplexes); and/or non-ionic surfactants such as TWEEN™, PLURONICS™ orpolyethylene glycol (PEG).

The formulation herein may also contain more than one active compound asnecessary, preferably those with complementary activities that do notadversely affect each other. The type and effective amounts of suchmedicaments depend, for example, on the amount of antibody present inthe formulation, and clinical parameters of the subjects. Exemplary suchmedicaments are discussed below.

The active ingredients may also be entrapped in microcapsules prepared,for example, by coacervation techniques or by interfacialpolymerization, for example, hydroxymethylcellulose orgelatin-microcapsules and poly-(methylmethacylate) microcapsules,respectively, in colloidal drug delivery systems (for example,liposomes, albumin microspheres, microemulsions, nano-particles andnanocapsules) or in macroemulsions. Such techniques are disclosed inRemington's Pharmaceutical Sciences 16th edition, Osol, A. Ed. (1980).

Sustained-release preparations may be prepared. Suitable examples ofsustained-release preparations include semi-permeable matrices of solidhydrophobic polymers containing the antibody, which matrices are in theform of shaped articles, e.g. films, or microcapsules. Examples ofsustained-release matrices include polyesters, hydrogels (for example,poly(2-hydroxyethyl-methacrylate), or poly(vinylalcohol)), polylactides(U.S. Pat. No. 3,773,919), copolymers of L-glutamic acid and γethyl-L-glutamate, non-degradable ethylene-vinyl acetate, degradablelactic acid-glycolic acid copolymers such as the LUPRON DEPOT™(injectable microspheres composed of lactic acid-glycolic acid copolymerand leuprolide acetate), and poly-D-(−)-3-hydroxybutyric acid.

The formulations to be used for in vivo administration must be sterile.This is readily accomplished by filtration through sterile filtrationmembranes.

In one embodiment, the anti-IL-6R antibody-containing liquid formulationaccording to the present invention contains a high concentration of theanti-IL-6R antibody, preferably from 50 to 300 mg/mL, more preferablyfrom 100 to 300 mg/mL, still more preferably from 120 to 250 mg/mL, andyet more preferably from 150 to 200 mg/mL, for example about 180 mg/mL,of the anti-IL-6R antibody.

In one embodiment, the formulation with high anti-IL-6R antibodyconcentration includes arginine and/or methionine as stabilizers orexcipients in the formulation.

As the arginine used in the present invention, any of the argininecompound per se, derivatives thereof and salts thereof can be used.L-arginine and salts thereof are preferred. As the methionine used inthe present invention, any of the methionine compound per se,derivatives thereof and salts thereof can be used. L-methionine andsalts thereof are preferred. In cases where the antibody-containingliquid formulation according to the present invention contains arginineand does not contain methionine, the concentration of arginine ispreferably 50 to 1500 mM, more preferably 100 to 1000 mM, still morepreferably 200 to 700 mM. In cases where the antibody-containing liquidformulation according to the present invention contains arginine andmethionine, the total concentration of arginine and methionine ispreferably 50 to 1200 mM, for example, preferably, the arginineconcentration is 40 to 1000 mM and the methionine concentration is 10 to200 mM; more preferably, the arginine concentration is 50 to 700 mM andthe methionine concentration is 10 to 100 mM; and still more preferably,the arginine concentration is 100 to 300 mM, and the methionineconcentration is 10 to 50 mM.

The buffer solution is prepared using a buffering agent which is asubstance for maintaining a pH of the solution. In a high concentrationantibody-containing liquid formulation according to the presentinvention, a pH of the formulation is preferably 5 to 7, more preferably5.5 to 6.5, and most preferably pH 6. A buffering agent which can beused in the present invention is one which can adjust the pH in thisrange and which is pharmaceutically acceptable. Such a buffering agentis known by those skilled in the art, and examples thereof includeinorganic salts such as phosphoric acid salts (sodium or potassium) andsodium hydrogen carbonate; organic acid salts such as citric acid salts(sodium or potassium), sodium acetate and sodium succinate; and acidssuch as phosphoric acid, carbonic acid, citric acid, succinic acid,malic acid and gluconic acid. Further, Tris buffers, Good's buffers suchas MES, MOPS and HEPES, histidine (e.g., histidine hydrochloric acidsalt) and glycine can also be used. The buffer is preferably a histidinebuffer or glycine buffer, and a histidine buffer is especiallypreferred. The concentration of the buffer solution is generally 1 to500 mM, preferably 5 to 100 mM, still more preferably 10 to 20 mM. Incases where a histidine buffer is used, the buffer solution containshistidine at a concentration of preferably 5 to 25 mM, more preferably10 to 20 mM.

The formulation according to the present invention can further contain asurfactant. Typical examples of the surfactant include nonionicsurfactants, for example, sorbitan fatty acid esters such as sorbitanmonocaprylate, sorbitan monolaurate and sorbitan monopalmitate; glycerinfatty acid esters such as glycerol monocaprylate, glycerol monomyristateand glycerol monostearate; polyglycerol fatty acid esters such asdecaglyceryl monostearate, decaglyceryl distearate and decaglycerylmonolinoleate; polyoxyethylene sorbitan fatty acid esters such aspolyoxyethylene sorbitan monolaurate, polyoxyethylene sorbitanmonooleate, polyoxyethylenesorbitan monostearate, polyoxyethylenesorbitan monopalmitate, polyoxyethylene sorbitan trioleate andpolyoxyethylene sorbitan tristearate; polyoxyethylene sorbitol fattyacid esters such as polyoxyethylene sorbitol tetrastearate andpolyoxyethylene sorbitol tetra oleate; polyoxyethylene glycerin fattyacid esters such as polyoxyethylene glyceryl monostearate; polyethyleneglycol fatty acid esters such as polyethylene glycol distearate;polyoxyethylene alkyl ethers such as polyoxyethylene lauryl ether;polyoxyethylene polyoxypropylene alkyl ethers such as polyoxyethylenepolyoxypropylene glycol ether, polyoxyethylene polyoxypropylene propylether and polyoxyethylene polyoxypropylene cetyl ether; polyoxyethylenealkyl phenyl ethers such as polyoxyethylene nonylphenyl ether;polyoxyethylene hardened castor oils such as polyoxyethylene castor oiland polyoxyethylene hardened castor oil (polyoxyethylene hydrogenatedcastor oil); polyoxyethylene bees wax derivatives such aspolyoxyethylene sorbitol bees wax; polyoxyethylene lanolin derivativessuch as polyoxyethylene lanolin; surfactants having an HLB of 6 to 18such as polyoxyethylene fatty acid amides, for example, polyoxyethyleneoctadecanamide; anionic surfactants, for example, alkyl sulfate saltshaving a C₁₀-C₁₈ alkyl group, such as sodium cetyl sulfate, sodiumlauryl sulfate and sodium oleyl sulfate; polyoxyethylene alkyl ethersulfate salts in which the average number of moles of the added ethyleneoxide units is 2 to 4 and the number of carbon atoms of the alkyl groupis 10 to 18, such as polyoxyethylene sodium lauryl sulfate; alkylsulfosuccinate salts having a C₈-C₁₈ alkyl group, such as sodium laurylsulfosuccinate; natural surfactants such as lecithin andglycerophospholipids; sphingophospholipids such as sphingomyelin; andsucrose esters of C₁₂-C₁₈ fatty acids. These surfactants can be added tothe formulation of the present invention individually, or two or more ofthese surfactants can be added in combination.

Preferred surfactants are polyoxyethylene sorbitan fatty acid esters andpolyoxyethylene polyoxypropylene alkyl ethers, and especially preferredare polysorbates 20, 21, 40, 60, 65, 80, 81 and 85, and Pluronic typesurfactants, and most preferred are polysorbates 20 and 80, and PluronicF-68 (Poloxamer 188).

The amount of the surfactant(s) to be added to the antibody formulationaccording to the present invention is generally 0.0001 to 10% (w/v),preferably 0.001 to 5%, more preferably 0.005 to 3%.

In one embodiment, the formulation according to the present inventioncomprises: (a) anti-IL-6 receptor antibody; (b) buffering agent(s) (e.g.histidine buffer); (c) one or more amino acids as stabilizers (e.g.arginine and/or methionine); and (d) one or more surfactant(s).

In one embodiment, the formulation additionally includes one or morehyaluronidases (e.g. rHuPH20) in an amount which allows theadministration of higher volumes of drug product and/or for enhancingabsorption of subcutaneously administered anti-IL-6R antibody into thesystemic circulation of a patient treated with the formulation.

According to this embodiment of the invention, a pharmaceuticalcomposition is provided comprising: an anti-IL-6R antibody (e.g.tocilizumab) in an amount from about 100 mg/mL to about 300 mg/mL (e.g.180 mg/mL), and hyaluronidase enzyme in an amount from about 1,400 toabout 1,600 U/mL (e.g. about 1,500 U/mL). Preferably the compositionfurther comprises a buffer (for instance, wherein the buffer ishistidine, pH 5.5 to 6.5) and/or one or more stabilizers (for example,methionine, arginine, and polysorbate).

The concentration of the hyaluronidase enzyme in the formulation isprovided in sufficient amount so that an increase in the dispersion andabsorption of the co-administered anti-IL-6R antibody is achieved. Theeffective amount of the hyaluronidase enzyme is preferably about 1,000to 16,000 U/ml, whereby the amount corresponds to about 0.01 mg to 0.15mg protein based on an assumed specific activity of 100,000 U/mg. Thepreferred concentration of the hyaluronidase enzyme in the formulationis about 1,400 U/mL to 1,600 U/mL, most preferred is a concentration ofabout 1,500 U/mL.

The hyaluronidase enzyme may be derived from animals, human samples ormanufactured based on recombinant DNA technology. Most preferred isrecombinant human PH20 (rhPH20).

Preferably the formulation is isotonic.

IV. Therapeutic Uses of Anti-IL-6R Antibodies

In one aspect, the invention provides a method of treating anIL-6-mediated disorder in a patient comprising subcutaneouslyadministering an anti-IL-6 receptor (IL-6R) antibody to the patient,wherein the anti-IL-6R antibody is administered as a fixed dose of 162mg per dose (e.g every week, every two weeks, or every ten days).

Examples of IL-6-mediated disorders to be treated herein include:autoimmune diseases, osteoporosis, neoplasia, aging, rheumatoidarthritis (RA), juvenile idiopathic arthritis (JIA) (including systemicJIA (sJIA) and polyarticular course JIA (pcJIA)), psoriatic arthritis,Castleman's disease, Crohn's disease, multiple myeloma, polymyalgiarheumatica, glomerulonephritis, plasmacytoma or plasmacytosis, myeloma(including multiple myeloma), hyperimmunoglobulinemia, anemia, nephritis(such as mesangium proliferative nephritis), cachexia (includingcancerous cachexia), tumors, T cell mediated disease (e.g. uveitis,chronic thyroiditis, delayed hypersensitivity, contact dermatitis, oratopic dermatitis), lupus (including lupus nephritis and systemic lupuserythmatosus), inflammatory bowel disease (including Crohn's disease andulcerative colitis), pancreatitis, psoriasis, osteoarthritis,adult-onset Still's disease, mesothelioma, vasculitis, islettransplantation (e.g. pancreatic islet transplantation), myocardialinfarction (heart failure, ischemia-induced severe arrhythmia), hearttransplantation, prostate cancer, choroidal neovascularization (e.g.age-related macular degeneration, idiopathic choroidalneovascularization, cyopic choroidal neovascularization, idiopathicchoroidal neovascularization), muscle atrophy, chronic rejection, ocularinflammatory disease (e.g. panuveitis, anterior aveitis, intermediateuveitis, scleritis, keratitis, orbital inflammation, optic neuritis, dryeye, diabetic retinopathy, proliferative vitreoretinopathy,postoperative inflammation), graft versus host disease (GVHD), fibroticdisorders (such as systemic sclerosis), giant cell arteritis (GCA),ankylosing spondylitis, and Takayasu's arteritis (TA), arteritis nodosa,etc.

In one embodiment, the IL-6-mediated disorder is rheumatoid arthritis.

In one embodiment, the IL-6 mediated disorder is juvenile idiopathicarthritis (JIA).

In one embodiment, the IL-6 mediated disorder is systemic JIA (sJIA).

In one embodiment, the IL-6 mediated disorder is polyarticular courseJIA (pcJIA).

In one embodiment, the IL-6 mediated disorder is systemic sclerosis.

In one embodiment, the IL-6 mediated disorder is giant cell arteritis(GCA).

In one embodiment, the IL-6 mediated disorder is psoriatic arthritis.

In one embodiment, the IL-6 mediated disorder is uveitis.

In one embodiment, the patient to be treated has rheumatoid arthritis,with such patients including DMARD-inadequate responder patients,TNF-inhibitor-inadequate responder patients, patients who aremethotrexate (MTX) naive or have discontinued MTX, patients with activedisease, patients with moderate-severe RA etc.

In one embodiment, the method comprises treating rheumatoid arthritis ina patient by subcutaneously administering tociluzumab to the patient,wherein the tociliuzmab is administered as a fixed dose of 162 mg perdose every week or every two weeks. Optionally, the patient isadditionally treated with one or more non-biological disease modifyinganti-rheumatic drugs (DMARDs), such as methotrexate etc.

The invention also concerns a method of inhibiting progression ofstructural joint damage in a rheumatoid arthritis (RA) patient bysubcutaneously administering a fixed dose of 162 mg of an anti-IL-6Rantibody to the patient every two weeks. According to this method,structural joint damage can be assessed at week 24 (or 6 months) and/orweek 48 (or 1 year) and found to be inhibited (e.g. relative to apatient not treated with the anti-IL-6R antibody).

The invention additionally provides a method of treating anIL-6-mediated disorder (such as RA) in a patient comprisingsubcutaneously administering an anti-IL-6R antibody (e.g. tocilizumab)and a hyaluronidase enzyme (e.g., rhPH20) to a patient, wherein theanti-IL-6R antibody is administered as a fixed dose of 324 mg per doseor 648 mg per dose. Preferably, the fixed dose is administered everyfour weeks or once a month. Optionally, the anti-IL-6R antibody andhyaluronidase enzyme are co-formulated or combined into a singlepharmaceutical composition which is subcutaneously administered to thepatient.

According to the present invention, the anti-IL-6R antibody may beadministered with a hyaluronidase enzyme, such as rHuPH20. The finaldose of the rHuPH20 depends on the volume of formulation administered.Exemplary doses of the hyaluronidase administered are in the range from1,000 to 10,000 U, e.g. about 1,350 U, about 2,700 U, or about 5,400 U.For example, 1,350 U of rHuPH20 is administered in 0.9 mL; 2,700 U ofrHuPH20 in 1.8 mL; or 5,400 U of rHuPH20 in 3.6 mL. The anti-IL-6Rantibody and hyaluronidase enzyme may be administered concurrently orsequentially, in the same, or separate formulations. Preferably theantibody and enzyme are co-formulated and administered concurrently,e.g. via a single SC administration device.

In one embodiment, the anti-IL-6R antibody (e.g. tocilizumab) issubcutaneously administered to a patient with juvenile idiopathicarthritis (JIA) in an amount effective to treat the JIA.

In one embodiment, the patient has systemic JIA (sJIA). Such sJIApatient is optionally treated with 162 mg of the antibody (e.g. oftocilizumab) every week if the patient's weight is ≥30 kilograms, andwith 162 mg of the antibody (e.g. of tociliumab) every 10 (±1) days ifthe patient's weight is <30 kilograms. In an alternative embodiment, thesJIA patient whose weight is <30 kilograms is treated with 162 mg of theantibody (e.g. of tocilizumab) every week or every two weeks. In yetanother embodiment, the sJIA patient whose weight is <30 kilograms istreated with 108 mg of the antibody (e.g. of tocilizumab) every week.

In another embodiment, the patient has polyarticular course (pcJIA).Such patient is optionally treated with 162 mg of the antibody (e.g. oftocilizumab) every two weeks.

In another embodiment, the anti-IL-6R antibody is subcutaneouslyadministered to a patient with a fibrotic disease (such as systemicsclerosis) in an amount effective to treat the fibrotic disease. Wherethe disorder is systemic sclerosis, the treatment optionally improvescutaneous sclerosis (e.g. as assessed by modified Rodnan skin score(mRSS)), improves physical function (e.g. as assessed by SclerodermaHealth Assessment Questionnaire-Disability Index (HAQ-DI)), and/or slowsprogression of organ damage, relative to placebo. For treatment offibrotic disease, such as systemic sclerosis, the antibody (e.g.tocilizumab) is optionally administered as a fixed dose of 162 mg perdose, for instance every week, or every two weeks.

In a further embodiment, the anti-IL-6R antibody is subcutaneouslyadministered to treat giant cell arteritis (GCA) in an amount effectiveto treat the GCA. Optionally, the antibody is administered to the GCApatient as a fixed dose of 162 mg per dose (e.g. every week. or everytwo weeks). The GCA patient optionally is further treated with aninitial (short) course or corticosteroid. Such treatment of GCA mayreduce signs and symptoms of GCA, maintain clinical remission, and/orreduce or stop corticosteroid use in the GCA patient. The GCA hereinincludes new onset GCA and refractory GCA, optionally in adult patients.

In one embodiment of all the methods herein, no other medicament thanthe anti-IL-6R antibody (optionally co-formulated with the hyaluronidaseenzyme) is administered to the subject to treat the IL-6-mediateddisorder.

In another embodiment of any of the methods herein, one may administerto the subject along with the anti-IL-6R antibody an effective amount ofone or more additional drug that treats the disorder. The additionaldrug may be one or more medicaments, and include, for example,immunosuppressive agents, non-steroidal anti-inflammatory drugs(NSAIDs), disease modifying anti-rheumatic drugs (DMARDs), methotrexate(MTX), anti-B-cell surface marker antibodies, anti-CD20 antibodies,rituximab, TNF-inhibitors, corticosteroids, and co-stimulatorymodifiers, or any combination thereof.

Examples of such additional drugs include an immunosuppressive agent(such as mitoxantrone (NOVANTRONE), methotrexate, cyclophosphamide,chlorambucil, leflunomide, and azathioprine), intravenous immunoglobulin(gamma globulin), lymphocyte-depleting therapy (e.g., mitoxantrone,cyclophosphamide, CAMPATH™ antibodies, anti-CD4, cladribine, apolypeptide construct with at least two domains comprising ade-immunized, autoreactive antigen or its fragment that is specificallyrecognized by the Ig receptors of autoreactive B-cells (WO 2003/68822),total body irradiation, bone marrow transplantation), integrinantagonist or antibody (e.g., an LFA-1 antibody such asefalizumab/RAPTIVA® commercially available from Genentech, or an alpha 4integrin antibody such as natalizumab/ANTEGREN® available from Biogen,or others as noted above), steroid such as corticosteroid (e.g.,prednisolone, methylprednisolone such as SOLU-MEDROL™ methylprednisolonesodium succinate for injection, prednisone such as low-dose prednisone,dexamethasone, or glucocorticoid, e.g., via joint injection, includingsystemic corticosteroid therapy), non-lymphocyte-depletingimmunosuppressive therapy (e.g., MMF or cyclosporine),cholesterol-lowering drug of the “statin” class (which includescerivastatin (BAYCOL™), fluvastatin (LESCOL™), atorvastatin (LIPITOR™),lovastatin (MEVACOR™), pravastatin (PRAVACHOL™), and simvastatin(ZOCOR™)), estradiol, testosterone (optionally at elevated dosages;Stuve et al. Neurology 8:290-301 (2002)), androgen, hormone-replacementtherapy, a TNF inhibitor such as an antibody to TNF-alpha, DMARD, NSAID,plasmapheresis or plasma exchange, trimethoprim-sulfamethoxazole(BACTRIM™, SEPTRA™), mycophenolate mofetil, H2-blockers or proton-pumpinhibitors (during the use of potentially ulcerogenic immunosuppressivetherapy), levothyroxine, cyclosporin A (e.g. SANDIMMUNE®), somatastatinanalogue, a DMARD or NSAID, cytokine antagonist such as antibody,anti-metabolite, immunosuppressive agent, rehabilitative surgery,radioiodine, thyroidectomy, BAFF antagonist such as BAFF or BR3antibodies or immunoadhesins, anti-CD40 receptor or anti-CD40 ligand(CD154), B-cell antagonists or antibodies, including anti-CD20antibodies such as rituximab or ofatumumab; IL-1 blockers, such asrHUIL-1Ra (Anakira, Amgen-Synergen) and tiaprofenic acid I-1B inhibitor(Hoechst); and co-stimulatory modifiers, such as CTLA-4-Ig fusionprotein ORENCIA® (abatacept) (Bristol-Myers Squibb); enlimomab(anti-ICAM-1 monoclonal antibody); CDO-855 (humanized antibody, whichbinds specifically to a region of the Class II MHC complex, Celltech);CH-3298 (Chiroscience); acemetacin (Merck); GW353430 (anti-CD23monoclonal antibody, Glaxo Wellcome); GR 252025 (COX02 inhibitor, GlaxoWellcome); 4162W94 (anti-CD4 humanized antibody; Glaxo Wellcome);azathioprine (DMARD, Glaxo Welcome); penicilamine and fenoprofen (EliLilly); etc.

Optionally, the second or additional drug is selected from the groupconsisting of non-biological DMARDS, NSAIDs, and corticosteroids.

These additional drugs as set forth herein are generally used in thesame dosages and with administration routes as used hereinbefore orabout from 1 to 99% of the heretofore-employed dosages. If suchadditional drugs are used at all, preferably, they are used in loweramounts than if the first medicament were not present, especially insubsequent dosings beyond the initial dosing with the first medicament,so as to eliminate or reduce side effects caused thereby.

The combined administration of an additional drug includesco-administration (concurrent administration), using separateformulations or a single pharmaceutical formulation, and consecutiveadministration in either order, wherein preferably there is a timeperiod while both (or all) active agents (medicaments) simultaneouslyexert their biological activities.

In one embodiment, before or after the SC doses are administered, thepatient may be treated with anti-IL-6R antibody which is administeredIV.

V. Articles of Manufacture

In another embodiment of the invention, articles of manufacturecontaining materials useful for the treatment of IL-6-mediated disordersdescribed above are provided. The invention, in particular, provides anarticle of manufacture comprising a subcutaneous administration device,which delivers to a patient a fixed dose of an anti-IL-6 receptor(IL-6R) antibody, wherein the fixed dose is selected from the groupconsisting of 162 mg, 324 mg, and 648 mg of the anti-IL-6R antibody.Preferably the anti-IL-6R antibody is tocilizumab. Preferably, theconcentration of the antibody in the device is from 150 to 200 mg/mL,for example 180 mg/mL. The antibody in the syringe is preferablyformulated in a buffer (e.g. histidine, pH 6) and other excipients (suchas methionine, arginine, and polysorbate) such that it is provided in astable pharmaceutical formulation in the syringe. Optionally, ahyaluronidase, such as rHuPH20, is included in the formulation, forexample, in an amount from about 1,400 U/mL to about 1,600 U/mL (e.g.about 1,500 U/mL). Optionally, the device delivers 0.9 mL, 1.8 mL, or3.6 mL of the formulation to a subject.

Devices suitable for SC delivery include: a syringe (including apre-filled syringe); an injection device (e.g. the INJECT-EASE™ andGENJECT™ device); an infusion pump (such as e.g. Accu-Chek™); aninjector pen (such as the GENPEN™); a needleless device (e.g. MEDDECTOR™and BIOJECTOR™); an autoinjector, a subcutaneous patch delivery system,etc.

The article of manufacture optionally further comprises a package insertwith instructions for treating an IL-6-mediated disorder (e.g. RA) in asubject, wherein the instructions indicate that treatment with theantibody as disclosed herein treats the IL-6-mediated disorder, andoptionally inhibits progression of structural joint damage (e.g. in a RApatient).

Further details of the invention are illustrated by the followingnon-limiting Examples. The disclosures of all citations in thespecification are expressly incorporated herein by reference.

Example 1 Clinical Studies Identifying Fixed Dose of Anti-IL-6R Antibodyfor Subcutaneous (SC) Administration

The selection of 162 mg anti-IL-6R antibody (tocilizumab, TCZ)subcutaneously administered every week (SC QW) was based on results fromfour phase 1/2 studies, including two phase 1 studies in healthysubjects (WP18097 and BP22065), one phase 1/2 study in Japanese RApatients (MRA227), and one phase 1b study in Caucasian RA patients(NP22623). Further details regarding these SC studies and the fourstudies from which data are drawn for comparison are provided in Table1.

TABLE 1 Clinical Pharmacology Studies Following SC Administration of TCZin Healthy Subjects and RA Patients Study No. TCZ Treatment/ CountryObjectives Design and Population Dose Duration Sample Size StatusWP18097 PK from a pilot SC Single center, single- Group 1: 160 mg Singledose, PK N = 20 total and Completed France formulation, blind, placebo-SC sampling up to Day 14, n = 12 for SC absolute controlled, randomized,Group 2: 160 mg one-week follow-up. group and 8 for bioavailability, 2groups study in IV TCZ antibody at IV group tolerability and HealthyVolunteers baseline, day 14 and immunogenicity follow-up BP22065 PK, PD,safety, Open-label, single- SC injection in Single dose for each N = 48total and Completed UK tolerability, center study to abdominal region:group, PK and PD n = 12 for each immunogenicity and characterize the PKand Group 1: 162 mg sampling up to Day 25, group absolute PD of TCZfollowing Group 2: 81 mg one week follow up. bioavailability single doseIV infusion: TCZ antibody at using SC administration by SC Group 3: 162mg baseline, day 25 and formulation of and IV routes to Group 4: 81 mgfollow-up TCZ Healthy Volunteers NP22623 PK, PD, safety, Open label,multicenter, Group 1: TCZ 162 12 weeks of treatment. N = 29 total and 29enrolled, study Spain, New immunogenicity and randomized, parallel mg QWPK/PD sampling from n = 14 for TCZ ongoing Zealand, and efficacy studyin RA patients Group 2: 162 mg baseline to the end of QW and n = 15Preliminary data Canada TCZ Q2W in study. Patients have for TCZ Q2Wsummary for combination with option to be rolled over efficacy andsafety MTX in patients to a provisional care are available with activeRA program for one year treatment (8 mg/kg IV) MRA227 PK, PD, safety,Combined single- and Group 1: TCZ 81 Single dose in Group 1 N = 32 total32 enrolled, study Japan immunogenicity and multi-dosing study in mgsingle dose and 2 is followed by 3 n = 8 in Group 1 ongoing efficacy RApatients. 3 Groups. followed by Q2W weeks PK and PD and n = 12 eachPreliminary data Dose escalation is Group 2: TCZ 162 sampling for Groups2 and summary for based on the safety and mg single dose Multi-dosingfor all 3 3 PK/PD/efficacy efficacy from previous followed by Q2W groupsis for 3 doses (6 and for safety are group. Group3: TCZ 162 weeks forQ2W and 3 available mg QW weeks for QW) followed by 24 weeks ofextension

These studies used a TCZ formulation with 180 mg/mL TCZ and nohyaluronidase (see Table 2 in Example 4).

In the Japanese RA study MRA227, all (32) patients were randomized intoone of 3 study arms: 81 mg SC Q2W/QW, 162 mg SC Q2W, and 162 mg SC QW.In the Caucasian RA study NP22623, a total of 29 patients wererandomized into one of 2 treatment arms: 162 mg SC Q2W (N=15) and 162 mgSC QW (N=14).

The observed data from the two RA patient studies form the primary basison which the dose rationale has been built.

The selection of this 162 mg QW dose regimen was driven by three keyelements:

-   -   The sIL-6R-bound TCZ complex (PD biomarker of TCZ mechanism of        action; Nishimoto et al., Blood 112(10):3959-3964 (2008)        increases more rapidly and to a greater magnitude for 162 mg QW        than for other SC dose regimens tested (FIG. 1)    -   CRP is reduced more rapidly and consistently with the 162 mg QW        than with the other SC dose regimens tested (FIG. 2)    -   The safety profile for the SC treatment arms do not appear to be        different from each other or from 8 mg/kg IV Q4W.        -   In general, the SC dose regimens tested have been well            tolerated in the MRA227 and NP22623 studies.        -   Notably there have been no deaths and only one SAE            (pyelonephritis) in the SC treatment arms.        -   Given that mean exposure (AUC, C_(max)) is generally higher            for 8 mg/kg IV Q4W than for any of the SC dose regimens, the            safety profile for 162 mg QW is expected to be similar to            that of 8 mg/kg IV (FIG. 4).            sIL-6R

FIG. 1 demonstrates sIL-6R profiles following both SC and IV regimens.sIL-6R profiles for RA patients receiving 162 mg QW most closely mirrorsthat observed with 8 mg/kg IV Q4W, both with respect to the rapidity andmagnitude of rise. The other dose regimens (81 mg Q2W/QW or 162 mg Q2W)tested did not reach levels comparable to 8 mg/kg IV Q4W.

CRP

FIG. 2 displays the CRP profile following the 162 mg SC QW and 8 mg/kgIV Q4W dose regimens in RA patients. 162 mg QW has the most rapid andsustained reduction of CRP levels of the SC dose regimens tested.

DAS28-ESR

Disease activity (as measured by DAS28-ESR) appears to decrease frombaseline more rapidly and to a greater magnitude with the 162 mg SC QWas compared to the other SC dose regimens tested (FIG. 3).

Safety: Observed Data

No deaths and only one SAE (pyelonephritis in the 81 mg dose group) havebeen reported in the 4 TCZ SC studies. AEs observed following single ormultiple SC doses for either healthy subjects or RA patients weregenerally consistent with the types and severity of AEs observed inPhase 3 RA W studies. Data from NP22623 did not demonstrate different AEprofiles between the 162 mg QW and Q2W dose groups. The magnitude ofmean changes in laboratory values for both Japanese RA and Caucasian RApatients receiving SC TCZ resembled that of RA patients from the Wprogram. One Japanese RA patient who received 162 mg QW experiencedneutropenia and the dose was reduced to 162 mg Q2W. One patient whoreceived 81 mg Q2W experienced neutropenia and was not dosed furtherwhen switched to 81 mg QW at week 11. The SC injection was generallywell tolerated. The SC injection was not perceived as more painful thanthe subcutaneous placebo injection.

In study MRA227, none of the patients tested positive for anti-TCZantibodies from the 162 mg QW group. Four patients from the lower dosegroups were anti-TCZ antibody positive (all from the 81 mg QW/Q2W dosegroup, one patient prior to TCZ administration); five patients wereanti-TCZ IgE antibody positive (3 patients in the 81 mg Q2W/QW dosegroup and 2 patients in the 162 mg Q2W dose group). Among those withpositive antibody tests, the patient positive at baseline experiencedgrade 1 eczema which was considered as unrelated (food allergy), onepatient experienced grade 1 urticaria, and another patient experiencedinjection site bruising. No other AEs were reported in the “Skin andSubcutaneous Tissue” and “General Disorders and administration siteconditions” classes in patients who tested positive for anti-TCZantibodies.

PK-Safety Relationship

On visual inspection of steady state PK profiles between SC and IVregimens from study MRA227 and LRO301, respectively, there appears to bein general higher exposure (mean AUC, C_(max)) with the 8 mg/kg IVregimen as compared to the 162 mg QW SC regimen (FIG. 4). The exceptionis the mean C_(trough) for which the 162 mg QW regimen results in ahigher level than for the 8 mg/kg IV regimen (26±15 μg/mL at week 15 and16±11 μg/mL at week 16, respectively). Other lower dose groups did notachieve C_(trough) concentrations similar to 8 mg/kg IV at steady state.Inter-subject variability for C_(trough) for the 162 mg SC regimen ishigh (58%). It is anticipated that since the exposure is generallyhigher for the 8 mg/kg IV Q4W dose regimens than any of the SC doseregimens, the safety profile for 162 mg SC QW would be similar to thatof 8 mg/kg IV Q4W.

A single fixed dose (162 mg QW dose) is administered for all RApatients, irrespective of body weight. This approach is supported by thefact that even after accounting for differences in exposure that couldresult from the full range of body weights on a fixed dose, the highestexposure for all 3 categories (C_(max), C_(trough) and AUC) with the 162mg QW dose regimen that has been observed is within the range that hasbeen described for the W program.

Additionally this approach is supported by analyses of safety data(SAEs, AEs, laboratory) from the W program. There is no apparentrelationship between TCZ exposure and the occurrence of adverse eventsby class and especially for the most frequent adverse events in the“Infections and Infestations” and “Skin and Subcutaneous Tissue”classes. There is no apparent relationship between exposure of TCZ andthe occurrence of serious adverse events. Except for neutropenia, therewas no obvious increase in the frequency of laboratory abnormalitieswith increasing exposure. A slightly greater proportion of patientsexperienced Grade 3 or higher events of neutropenia in the higher TCZexposure categories. In addition, there were single Grade 3 events ofthrombocytopenia in the higher TCZ exposure categories. With respect totriglycerides, total cholesterol, and LDL-cholesterol levels, a slightlygreater proportion of patients developed an increase in levels in thehigher TCZ exposure categories. Taken altogether, these data suggestthat use of a fixed dose regimen is acceptable.

In summary, the 162 mg SC QW dose regimen has been selected on the basisof: 1) sIL-6R-bound TCZ complex for 162 mg SC QW increased more rapidlyand to a greater magnitude for 162 mg SC QW, most similar to 8 mg/kg IVQ4W of the dose regimens tested; 2) CRP is reduced more rapidly andconsistently with the 162 mg SC QW than the other SC dose regimenstested; 3) the safety profile for the SC treatment arms do not appear tobe different from each other or from 8 mg/kg IV Q4W; and 4) given thatthe total exposure for 8 mg/kg IV Q4W is generally higher than for anyof the SC dose regimens tested, the safety profile for 162 mg SC QWshould be similar to 8 mg/kg IV Q4W.

Example 2 Clinical Study of SC Anti-IL-6 Receptor Antibody in RA

This is a Phase 3, 2-arm, 2-year, randomized, double-blind,double-dummy, active controlled, parallel group multicentre trial inpatients with moderate to severe, active RA who currently have aninadequate response to a stable dose of DMARDs that may include one ormore anti-TNF biological agent. The primary endpoint will be evaluatedat 24 weeks. The overall design of this example is shown in FIG. 5. Theformulation is that as in Example 1.

The screening visit can occur up to 21 days (or up to 56 days if awashout period is required for longer than 21 days) prior to thebaseline randomization visit. Patient eligibility will be determined atthe screening and baseline visits, at which time the patient will berandomized. The number of patients that have failed previous anti-TNFtreatment will be limited to approximately 20% of the total studypopulation.

Inclusion Criteria

-   1. Age ≥18 years-   2. Rheumatoid arthritis of ≥6 months duration, diagnosed according    to the revised 1987 American College of Rheumatology (ACR; formerly    American Rheumatism Association) criteria-   3. Swollen joint count (SJC)≥4 (66 joint count) and tender joint    count (TJC)≥4 (68 joint count) at screening and baseline.-   4. Prior to randomization, will have discontinued etanercept for ≥2    weeks, infliximab, certolizumab, golimumab, abatacept or adalimumab    for ≥8 weeks, anakinra for ≥1 week.-   5. Have received permitted DMARDs at a stable dose for at least 8    weeks prior to baseline.-   6. At screening either CRP≥1 mg/dL (10 mg/L) or ESR≥28 mm/hr.-   7. Oral corticosteroids (≤10 mg/day prednisone or equivalent) and    NSAIDs (up to the maximum recommended dose) are permitted if on a    stable dose regimen for ≥4 weeks prior to baseline.

In the double-blind period, at baseline visit, patients will berandomized in a 1:1 ratio to receive either TCZ 162 mg SC weekly andplacebo IV Q4W (Group A), or TCZ 8 mg/kg IV Q4W with placebo SC QW(Group B) for 24 weeks. The primary analysis will occur when allpatients reach Week 24.

At Week 24, all patients will be re-randomized for the open-label periodas follows:

-   -   Group A: patients will be re-randomized in an 11:1 ratio to        receive TCZ 162 mg SC weekly (group A1), or 8 mg/kg IV every        four weeks (group A2).    -   Group B: patients will be re-randomized in a 2:1 ratio to        receive 8 mg/kg IV every four weeks (group B1), or TCZ 162 mg SC        weekly (group B2).

Prior to the first dose of double-blind study medication (baselinevisit), patient-reported outcomes and efficacy assessments should beperformed within 24 hours (up to 72 hours will be allowed whennecessary). There will be a one-week dose interruption period betweenWeek 24 and 25 before the first treatment for the open-label period atWeek 25.

The efficacy parameters will be assessed at baseline, Week 2, Week 4 andthen every 4 weeks up to Week 24 and then Week 37, 49, 73 and 97 orearly withdraw (WD) visit.

Each treatment group is allowed background therapy with non-biologicalDMARD(s), corticosteroids and/or NSAIDs that were initiated prior to thestart of dosing with TCZ. Dosages of NSAIDs, corticosteroids, andnon-biological DMARDs should remain stable during the core study period(up to Week 24). However, reductions in these treatments will be allowedif required for safety reasons.

Assessment of Efficacy ACR20

The American College of Rheumatology (ACR) core set of outcome measuresand their definition of improvement includes a 20% improvement comparedto baseline in both SJC and TJC as well as in 3 out of 5 additionalparameters: physician's global assessment of disease activity, patient'sglobal assessment of disease activity, patient's assessment of pain,HAQ, and acute phase reactant (either CRP or ESR).

Achievement of an ACR50 requires a ≥50% improvement in the sameparameters and an ACR70 requires a ≥70% improvement.

Disease Activity Score 28 (DAS28)—ESR

The DAS28 is a combined index for measuring disease activity in RA. Theindex includes swollen and tender joint counts, acute phase response(ESR or CRP), and general health status. For this study ESR will be usedto calculate the DAS28 score. The index is calculated using thefollowing formula:

DAS28=0.56×√(TJC28)+0.28×√(SJC28)+0.36×ln(ESR+1)+0.014×GH+0.96

Where, TJC28=tender joint count on 28 joints, SJC28=swollen joint counton 28 joints, ln=natural log, ESR=Erythrocyte sedimentation rate(mm/hr), and GH=general health, i.e., patient's global assessment ofdisease activity (100-mm VAS). The DAS28 scale ranges from 0 to 10,where higher scores represent higher disease activity.

ACR-Hybrid

ACR-hybrid is a measure that combines the percent improvement of ACRcore parameters with the status of ACR20, ACR50 or ACR70.

It is anticipated that treatment with 162 mg TCZ given subcutaneously(SC) weekly as disclosed in this example will have comparable safety andefficacy as compared to 8 mg/kg TCZ given intravenously (IV) every 4weeks based on any one or more of the above efficacy criteria.

Example 3 Anti-IL-6R Antibody SC for Inhibiting Progression of JointDamage

This is a Phase 3, 2-arm, 2-year, randomized, double-blind,placebo-controlled, parallel group multicenter trial in patients withmoderate to severe, active RA who currently have an inadequate responseto DMARD(s) that may include one or more anti-TNF-α agent. The primaryendpoint will be evaluated at Week 24.

The overall design is shown in FIG. 6. The screening visit can occur upto 21 days (or up to 56 days if a washout period is required for longerthan 21 days) prior to the baseline randomization visit. Patienteligibility will be determined at the screening and baseline visits. Atbaseline, patients will be randomized. The number of patients that havefailed previous anti-TNF-α treatment will be limited to approximately20% of the total study population. The formulation is that as inExample 1. The formulation is administered using a pre-filled syringe(PFS) or auto-injector (AI) device.

TCZ Q2W Dosing

In this study, 162 mg of TCZ is administered every 2 weeks (Q2W) ratherthan every week (QW). Compared with the response seen with 162 mg SC QW,162 mg SC Q2W appears to be a lower SC dose option that, as describedbelow, increases sIL-6R-bound TCZ complex, achieves CRP normalizationand results in a DAS-ESR reduction from baseline. Further, the PDresponses and the preliminary efficacy readout for the 162 mg SC Q2Wregimen are superior to other lower SC regimens tested (81 mg Q2W/QW).

-   -   The sIL-6R Complex which is a PD biomarker of TCZ mechanism of        action increases with 162 mg SC Q2W less than with 162 mg SC QW        but increases to a greater magnitude as compared to other lower        SC regimens (81 mg Q2W/QW) (FIG. 1)    -   CRP normalization is reached with 162 mg SC Q2W; lower SC        regimens did not result in CRP normalization (FIG. 2)    -   Disease activity score DAS28-ECR appears to decrease from        baseline to a greater magnitude with 162 mg SC QW and 162 mg SC        Q2W as compared to the other SC dose regimens tested (81 mg SC        Q2W/QW). (FIG. 3)

Safety:

Based on available observed safety data, the safety profile for the SCtreatment arms do not appear to be different from each other or from theW program.

-   -   162 mg SC QW and Q2W have been well tolerated in MRA227 and        NP22623 studies.    -   There have been no deaths in any of the SC treatment arms. One        SAE of pyelonephritis occurred in the 81 mg SC dose group.    -   Given that mean exposure (AUC, C_(max), C_(trough)) is generally        higher for the 8 mg/kg IV dose than for 162 mg SC Q2W, the        safety profile for 162 mg SC Q2W is expected to be similar to        the IV program (FIG. 4).        sIL-6R Complex

The sIL-6R-bound TCZ complex is a PD biomarker of TCZ mechanism ofaction. FIG. 1 demonstrates sIL-6R profiles following both SC and Wregimens. sIL-6R profiles for RA patients receiving 162 mg SC QW mostclosely mirrors that observed with 8 mg/kg IV q4w, both with respect tothe rapidity and magnitude of rise. The other dose regimens (81 mgQ2W/QW and 162 mg Q2W) tested did not reach levels comparable to 8 mg/kgIV q4w. The dose of 162 mg every other week (Q2W) shows a response thatis lower than what is seen with 162 mg QW and 8 mg/kg IV. sIL-6R complexincreases to a greater magnitude with 162 mg SC Q2W than with otherlower SC regimens tested and with 4 mg/kg IV.

CRP

FIG. 2 displays the CRP profile following both SC and W dose regimens inRA patients. 162 mg SC QW has the most rapid and sustained reduction ofCRP levels of the SC dose regimens tested. Among lower SC regimens, CRPnormalization is reached with 162 mg SC Q2W (please note that in MRA227,patients were given a single dose (SD) on week 0 followed by multipledosing starting on week 3; dose was switched from 81 mg Q2W to QW atweek 9, see FIG. 2). Lower SC regimens (81 mg QW/Q2W) did not seem toresult in CRP normalization. Therefore, 162 mg SC Q2W appears to be alower SC dose option resulting in CRP normalization.

DAS28-ESR

FIG. 3 displays the DAS28-ESR change following both SC and IV doseregimens in RA patients. Although DAS28-ESR data for SC regimens arelimited, disease activity appears to decrease from baseline more rapidlyand to a greater magnitude with 162 mg SC QW and 162 mg SC Q2W ascompared to the other SC dose regimens tested (81 mg SC Q2W/QW) (FIG.3). Compared with the response seen with 162 mg SC QW, 162 mg SC Q2Wappears to be a lower SC dose option that achieves a DAS-ESR reductionfrom baseline.

PK & PK-Safety Relationship

Following multiple dose administration of TCZ to RA patients (MRA227),mean exposure (AUC, C_(max), C_(trough)) is generally higher for the 4 &8 mg/kg IV q4w dose than for 162 mg SC Q2W, with the exception of theC_(trough) level for 4 mg/kg IV q4w which is lower than the C_(trough)observed with 162 mg SC Q2W (FIG. 4). The safety profile for the IVprogram has been extensively studied. Taken altogether and compared to162 mg SC QW, the dose of 162 mg SC Q2W appears to be a lower SC doseoption with an acceptable safety profile based on drug exposure.

Mean exposure (AUC, C_(max), C_(trough)) is generally higher for the 4 &8 mg/kg IV q4w dose than for 162 mg SC Q2W, with the exception of theC_(trough) level for 4 mg/kg IV q4w which is lower than the C_(trough)observed with 162 mg SC Q2W (FIG. 4). The safety profile for the IVprogram has been extensively studied. Taken altogether and compared to162 mg SC QW, the dose of 162 mg SC Q2W appears to be a lower SC doseoption with an acceptable safety profile based on drug exposure.

A single fixed dose (162 mg SC Q2W and 162 mg SC QW for escape therapy)will be administered for all RA patients, irrespective of body weight.This approach is supported by the fact that even after accounting fordifferences in exposure that could result from the full range of bodyweights on a fixed dose, the highest exposure defined by 3 parameters(C_(max), C_(trough) and AUC) with the 162 mg SC QW and Q2W dose regimenthat has been observed or predicted is within the range that has beendescribed for the IV program. Additionally this approach is supported byanalyses of safety data (SAEs, AEs, laboratory) from the IV program.There is no apparent relationship between TCZ exposure and theoccurrence of adverse events by class, especially for the most frequentadverse events in the “Infections and Infestations” and “Skin andSubcutaneous Tissue” classes. There is no apparent relationship betweenexposure of TCZ and the occurrence of serious adverse events. Except forneutropenia, there was no obvious increase in the frequency oflaboratory abnormalities with increasing exposure; a slightly greaterproportion of patients experienced Grade 3 or higher events ofneutropenia in the higher TCZ exposure categories. In addition, therewere single Grade 3 events of thrombocytopenia in the higher TCZexposure categories. With respect to triglycerides, total cholesterol,and LDL-cholesterol levels, a slightly greater proportion of patientsdeveloped an increase in levels in the higher TCZ exposure categories.Taken altogether, these data suggest that use of a fixed dose regimen isacceptable. The effect of body weight on PK will be further assessed inthis study.

Observed Safety Data from SC Studies in RA Patients (MRA227 and NP22623)

All (32) patients have enrolled in the MRA227 study and 29 patients haveenrolled in the NP22623 study and received TCZ SC treatments including81 mg QW/Q2W (MRA227 only), 162 mg Q2W and 162 mg QW. The subcutaneousadministrations have been well tolerated in RA patients up to 33 weeksin the MRA227 study and up to 12 weeks in the NP22623 study. AEsobserved following administration of SC doses in RA patients weregenerally consistent with the types and severity of those observed inthe TCZ W Phase 3 studies.

No deaths have been reported in the 4 SC TCZ studies. One SAE ofpyelonephritis was reported in the 81 mg dose group. Limited data fromNP22623 did not demonstrate different AE profiles between the 162 mg SCQW and Q2W dose groups. The magnitude of mean changes in laboratoryvalues for both Japanese RA and Caucasian RA patients receiving SC TCZresembled that of RA patients from the IV program. One Japanese RApatient who received 162 mg SC QW experienced neutropenia and the dosewas reduced to 162 mg SC Q2W. One patient who received 81 mg SC Q2Wexperienced neutropenia and was not dosed further at week 11. The SC TCZinjection was generally well tolerated and not perceived as more painfulthan the SC placebo injection.

In study MRA227, none of the patients from the 162 mg QW group testedpositive for anti-TCZ antibodies. Four patients from the lower dosegroup were anti-TCZ antibody positive (all from the 81 mg QW/Q2W dosegroup, one patient prior to TCZ administration); five patients wereanti-TCZ IgE antibody positive (3 patients in the 81 mg Q2W/QW dosegroup and 2 patients in the 162 mg Q2W dose group). Among those withpositive antibody tests, the patient positive at baseline experiencedgrade 1 eczema which was considered as unrelated (food allergy), onepatient experienced grade 1 urticaria, and another patient experiencedinjection site bruising. No other AEs were reported in the “Skin andSubcutaneous Tissue” and “General Disorders and administration siteconditions” classes in patients who tested positive for anti-TCZantibodies. In NP22623, three patients tested anti-TCZ antibody positivewith the screening assay, but none were positive with the confirmatoryassay.

Summary

Previously, TCZ 162 mg SC weekly (QW) was selected as a comparator doseregimen for TCZ 8 mg/kg IV q4w. Of the remaining SC doses tested,observed PK, PD, efficacy, and safety data from RA patients demonstratethat 162 mg SC every other week (Q2W) is an appropriate lower SC doseoption for this study NA25220B.

At the baseline visit, patients will be randomized in a 2:1 ratio toreceive either TCZ 162 mg SC Q2W (group A), or placebo SC Q2W (group B)for 24 weeks. The primary analysis will occur when all patients havereached Week 24.

Starting from Week 24, all patients will receive open-label treatmentwith TCZ 162 mg SC Q2W and no patient will receive placebo injection.

In addition, at the Week 24 visit, patients will be re-randomized forthe open-label period as follows:

-   -   Group A: patients will be re-randomized at a 1:1 ratio to        receive TCZ 162 mg SC every other week, either using        autoinjector (AI) (group A1) or pre-filled syringe (PFS) (group        A2).    -   Group B: patients will be re-randomized at a 1:1 ratio to        receive TCZ 162 mg SC every other week, either using AI (group        B1) or PFS (group B2).

Prior to the first dose of double-blind study medication (baselinevisit), patient-reported outcomes and efficacy assessments should beperformed within 24 hours (up to 72 hours will be allowed whennecessary).

Efficacy parameters will be assessed at baseline, Week 2, Week 4 andthen every 4 weeks up to Week 40 and then Week 48, 60, 72, 84 and 96 orearly withdraw (WD) visit.

Separate radiographs of each hand and foot will be taken at screening,Weeks 24 and 48.

Treatment Groups

The individual treatment groups are:

Group A: ˜400 patients, TCZ 162 mg SC Q2W using PFS in the 24-weekdouble-blind period, and then re-randomized to:

-   -   Group A1: ˜200 patients, TCZ 162 mg SC q2w, using AI in the        open-label period.    -   Group A2: ˜200 patients, TCZ 162 mg SC q2w, using PFS in the        open-label period.        Group B: ˜200 patients, placebo SC Q2W using PFS in the 24-week        double-blind period, and then re-randomized to:    -   Group B1: ˜100 patients, TCZ 162 mg SC q2w, using AI in the        open-label period.    -   Group B2: ˜100 patients, TCZ 162 mg SC q2w, using PFS in the        open-label period.

Patients, site personnel, and sponsor will not know whether TCZ orplacebo is received in the double-blind period until all patients havecompleted the double-blind treatment period at Week 24 and all data forall patients up to that time point have been collected, locked andreported.

Each treatment group is required to receive background therapy withnon-biological DMARD(s) that are initiated and at a stable dose 8 weeksprior to the first dosing of TCZ. Dosages of non-biological DMARDs,NSAIDs and corticosteroids should remain stable during the core studyperiod (up to Week 248). Dosage of NSAIDs should remain stable up toweek 24. However, reductions in these treatments will be allowed ifrequired for safety reasons. Patients may also receive intra-articularsteroids and/or an increase in oral corticosteroid dosage (maximum doseof 10 mg total dose/day).

Primary and Secondary Study Endpoints Primary Endpoints

The primary endpoint is the proportion of patients with an ACR20response at Week 24.

Secondary Endpoints

Excluding the change from baseline in van der Heijde modified Sharpradiographic score to Week 48 all secondary endpoints will be formallytested. To ensure the alpha level is maintained at 5%, the secondaryendpoints will be tested using a pre-specified fixed sequence method.This method will be described in detail in the DAP.

-   1. Change from baseline* in the van der Heijde modified Sharp    radiographic score to Week 24.-   2. Change from baseline* in the van der Heijde modified Sharp    radiographic score to Week 48.-   3. Proportion of Patients with ACR50 responses at Week 24.-   4. Proportion of Patients with ACR70 responses at Week 24.-   5. Mean changes from baseline in the individual parameters of the    ACR core set Week 24.-   6. Major clinical response (ACR70 response maintained over 24 weeks    of treatment) at Week 48.-   7. Change in Disease Activity Score (DAS28) from baseline at Week    24.-   8. Change from baseline in HAQ-DI at Week 24.-   9. Proportion of Patients classified as Categorical DAS28 responders    (EULAR response) at Week 24.-   10. Proportion of patients achieving DAS28 low disease activity    (DAS≤3.2) at Week 24.-   11. Proportion of patients with change from baseline in HAQ≥0.3 at    Week 24.-   12. Proportion of patients with DAS28 score <2.6 (DAS remission) at    Week 24.-   13. Change in SF-36 subscale and summary scores from baseline to    Week 24.-   14. Time to onset of ACR20, 50, 70 by treatment group.-   15. Change from baseline in haemoglobin level at Week 24.    * The assessment taken prior to receiving first dose of study    medication is considered baseline.

Radiographic Assessments

Separate radiographs of each hand (posterior-anterior, PA) and each foot(anterior-posterior, AP) will be taken at screening, Weeks 24 and 48.Radiographs will be assessed using van der Heijde modified methodaccording to Sharp (van der Heijde, D. “How to read radiographsaccording to the Sharp/van der Heijde method.” J Rheumatol 27: 261-263(2000)).

All non-escape patients will receive TCZ SC Q2W starting from week 24.The radiographic analysis at Week 48 will compare patients randomized atbaseline to placebo with patients randomized to TCZ SC Q2W, both groupsreceiving active drug starting from week 24. It will be explored whetherthe rate of progression of structural damage differs between bothperiods. This will be particularly relevant in the group of patientsrandomized to placebo at baseline.

Treatment with SC anti-IL-6R antibody (TCZ), in combination with DMARDs,as disclosed in this example is anticipated to be effective (based onWeek 24 ACR20 data) and safe (with respect to AEs and laboratoryassessments). Moreover, treatment with SC anti-IL-6R antibody (TCZ) caninhibit progression of structural joint damage at Week 24 and Week 48,and improve physical function in RA patients.

Example 4 Anti-IL-6R Antibody Composition Including Hyaluronidase Enzyme

This example describes the development of a stable pharmaceuticalformulation including anti-IL-6R antibody (tocilizumab) andhyaluronidase enzyme (recombinant human PH20, rHuPH20).

Drug Substance

The anti-IL-6R antibody tocilizumab (see, e.g. U.S. Pat. No. 5,795,965)is an active ingredient in the formulation, used to treat RA or otherIL-6-mediated disorders.

The recombinant human PH20 (rHuPH20), see, e.g. U.S. Pat. No. 7,767,429,is included to increase the dispersion area of the SC injected TCZthereby allowing the SC injection of volumes greater than 2 mL as wellas potentially increasing the bioavailability compared to the SCformulation without hyaluronidase (see Example 5).

Selection of pH/Buffer

A pH for stabilizing tocilizumab SC vials 162 mg was found to beapproximately pH 6.0. The pH of 6.0±0.5 was therefore selected for thecurrent formulation. L-histidine/L-histidine monohydrochloride is addedto the formulation as buffering agent at a concentration of 20 mM, whichis within the normal concentration range of 10-100 mM for parenteralbuffers. The pH of approximately 6.0 achieved by using a predefinedratio of buffer salt and base and optionally, sodium hydroxide orhydrochloric acid can be used for pH adjustment.

Stabilizing Agents

Polysorbate 80 is added at a concentration of 0.2 mg/mL as a stabilizingagent to prevent potential mechanical stress (agitation)-induced andpotential freeze and thaw-induced instabilization of the protein.

L-arginine hydrochloride and L-methionine are added at a concentrationof 100 mM and 30 mM as stabilizing agents to prevent potential thermalstress-induced instabilization of the protein.

Formulation Development

The goal was to develop a stable and sterile liquid solution forsubcutaneous injection of tocilizumab.

Due to the higher concentration of tocilizumab, 180 mg/mL versus 20mg/mL used in the W formulation, the SC formulation was developed withregard to the effect of protein concentration on the ejection force andthe viscosity on a standard syringe. Volume of subcutaneous injection isideally 1 mL or less, so that high concentration of protein is needed indrug product. On the other hand, high viscosity which is caused by highconcentration of protein, increase injection force. From correlationbetween protein concentration and viscosity, the target tocilizumabconcentration was 180 mg/mL.

Table 2 compares exemplary tocilizumab SC-formulations with atocilizumab IV-formulation. The lyophilized SC-formulation with 114.3mg/mL TCZ was used in a previous human pharmacokinetic clinical studyconducted in France using 20 healthy volunteers. The purpose of thisearly study was to investigate the absolute bioavailability andtolerability of the subcutaneous route of administration.

TABLE 2 Comparison of anti-IL-6R Antibody Formulations Tocilizumab SCLyo Tocilizumab Tocilizumab Tocilizumab Vials 80 mg SC Vials SC SyringesTocilizumab IV- Reconstitute 162 mg/0.9 mL 162 mg/0.9 mL Co-formulatedIngredient formulation^(a) Solution ^(c) for phase 1 & 2 for phase 3with rHuPH20 Function Tocilizumab 20 mg/mL 114.3 mg/mL 180 mg/mL 180mg/mL 180 mg/mL Active concentration ingredient (Drug substance process)pH buffer Phosphate ^(b) Phosphate ^(d) Histidine ^(e) Histidine ^(e)Histidine ^(e) pH buffer Polysorbate 80 0.5 mg/mL 1.4 mg/mL 0.2 mg/mL0.2 mg/mL 0.2 mg/mL Stabilizing agent Sucrose 50 mg/mL 100 mg/mL — — —Osmolality adjustment Bulking Agent L-Arginine — — — 0.147 mg/mL ^(f) —Stabilizing agent L-Arginine — — 21.1 mg/mL ^(f) 20.9 mg/mL ^(f) 21.1mg/mL ^(f) Stabilizing hydrochloride agent L-Methionine — — 4.48 mg/mL^(g) 4.48 mg/mL ^(g) 4.48 mg/mL ^(g) Stabilizing agent Total volumeq.s.^(h) q.s.^(h) q.s.^(h) q.s.^(h) q.s.^(h) Diluent adjusted with Waterfor Injection Hyaluronidase — — — — 1,500 U/mL Increase (rHuPH20)dispersion and/or bioavailability ^(a)Currently available TocilizumabIV-strengths are: Vials 80 mg/4 mL, Vials 200 mg/10 mL and Vials 400mg/20 mL with different fill volume of the same formulation with thesame concentration of the drug substance. ^(b) pH of solution 6.5 and 15mmol/L for phosphate buffer ^(c) Each concentration of ingredient iscalculated from actual reconstituted volume (0.7 mL). ^(d) pH ofsolution 7.0 and 42.9 mmol/L for phosphate buffer ^(e) pH of solution6.0 and 20 mmol/L for histidine buffer ^(f) corresponds to aconcentration of 100 mmol/L L-Arginine hydrochloride ^(g) corresponds toa concentration of 30 mmol/L L-Methionine ^(h)q.s. = quantum satis (asmuch as may suffice)

Overages

No concentration overages are used in the formulation.

Formulation with Hyaluronidase Enzyme

The following table summarizes the ingredients and concentrationsthereof in an exemplary formulation including both anti-IL-6R antibody(TCZ) and hyaluronidase (rHuPH20):

TABLE 3 SC Formulation Ingredient Concentration Tocilizumab 180 mg/mLrHuPH20 1,500 U/mL Polysorbate 80 0.2 mg/mL L-Arginine hydrochloride21.1 mg/mL^(a) L-Methionine 4.5 mg/mL^(b) L-Histidine 1.5 mg q.s.^(c,d)L-Histidine monohydrochloride 2.1 mg q.s.^(c,d) Total volume adjustedwith Water 1 mL q.s.^(d) for Injection (WFI) ^(a)corresponds to aconcentration of 100 mmol/L L-arginine hydrochloride ^(b)corresponds toa concentration of 30 mmol/L L-methionine ^(c)pH of solution 6.0 and 20mmol/L for histidine buffer; sodium hydroxide or dilute hydrochloricacid can optionally be used for pH adjustment. ^(d)q.s = quantum satis(as much as may suffice) (L-Histidine, L-Histidine monohydrochloride,and WFI are potential amounts to achieve pH 6.0)

Physicochemical and Biological Properties

The formulation demonstrates good stability at the recommended storagecondition of 2-8° C. when protected from light.

PK Studies

Two non-clinical PK studies with the TCZ SC formulation includinghyaluronidase have been conducted; one in mini-pigs, and one inCynomolgus monkeys (Table 4):

TABLE 4 PK studies rHuPH20 Dose in SC Formulation Study Dosing TCZ doseVolume Total type Species regimen (mg) mg/mL U/mL (mL) Units EndpointsPK Mini-pig TCZ SC 180 0 0 1.0 0 TCZ (non single dose 180 0.02 2000 1.02000 in plasma - GLP) TCZ IV** 180 0.06 6000 1.0 6000 Absolute singledose 540 0.06 6000 3.0 18000 bioavailability  20* 0 0 ca. 1.0 0 PKCynomolgus TCZ SC  50* 0.06 6000 ca. 3   1800 TCZ in (non- monkey singleDose plasma GLP) *dose level in mg/kg **IV administration of TCZ toallow calculation of absolute bioavailability.

The mini-pig was chosen for rHuPH20 dose selection because its skin andthe texture of SC tissue are considered to be similar to those ofhumans. The mini-pig study utilized two SC dose levels of TCZformulations with various concentrations of rHuPH20 as well as an IVdosing arm with TCZ alone (Table 4) to allow estimation of absolutebioavailability/fraction absorbed. Study results indicated a more rapidabsorption of SC administered TCZ from rHuPH20 containing formulations.Thus, median time to maximum plasma levels of TCZ was shortened from 48hours without rHuPH20 to 24 hours for all rHuPH20 containingformulations. The fraction absorbed of SC administered TCZ was estimatedat around 80% for all dose groups.

The study in Cynomolgus monkey provided information about repeat-dosetoxicity with the TCZ SC formulation in the same species (Table 4).Plasma levels of TCZ following a single dose of 50 mg/kg of the TCZ SCformulation were assessed. Results demonstrate that after SCadministration maximum serum concentrations of TCZ (mean±SD: 822±230μg/mL) were reached after 48 hours (median). The results of this studyare available except for the animals which are currently in thetreatment-free recovery period. Subcutaneous weekly dosing oftocilizumab in a formulation containing recombinant hyaluronidase(rHuPH20) to Cynomolgus monkeys at 100 mg/kg for 13 weeks wassystemically and locally well tolerated, without any test item inducedfinding. The no adverse effect limit (NOAEL) was considered to be at thedose level of 100 mg/kg.

Example 5 Clinical Study with SC Formulation Including Anti-IL-6RAntibody and Hyaluronidase Enzyme

Tocilizumab (TCZ) is a recombinant humanized, IgG1 monoclonal antibodydirected against the soluble and membrane-bound interleukin 6 receptor(IL-6R). Hyaluronidase enzyme (rHuPH20) is used to facilitate injectionof subcutaneous (SC) formulations by cleaving the hyaluronic acid chainin the SC interstitial matrix at the injection site. The aim of thestudy was to evaluate pharmacokinetic (PK), pharmacodynamic (PD), andsafety following single ascending doses of TCZ with rHuPH20.

Materials and Methods

This was a phase 1 ascending dose (162 mg TCZ alone, 162 mg, 324 mg, and648 mg TCZ+rHuPH20) study in healthy subjects. The formulation ofExample 4, Table 3 was used in this study.

The objectives of the study were:

Primary Objective:

1. To investigate the effect of rHuPH20 on the exposure of different SCdoses of TCZ.

Secondary Objectives:

-   -   1. To explore the safety and tolerability of a single SC dose of        TCZ containing rHuPH20 in healthy volunteers.    -   2. To investigate the PK/pharmacodynamic (PD) relationship of        TCZ (with or without rHuPH20) following SC administration by        measuring IL-6, sIL-6R, and C-reactive protein (CRP) in healthy        volunteers.

Overall Study Design

This was a phase 1, single-dose, open-label, parallel group for Cohorts1 and 2 and sequential for the rest of the cohorts, single-center studyin healthy males and females 18 to 65 years of age, inclusive, ofnon-child-bearing potential. Table 5 provides an overview of the studydesign.

TABLE 5 Overview of Study Design Study drug Assess- Assess-administration/ ments Safety Screening ments assessments continuedfollow-up Days −28 Day −1 Day 1 Days 2 Between to −2 Single dose to 36days 40 of study drug and 43 administration In-clinic stay from day −1(evening) to day 2 (morning)

Eligible subjects were assigned to one of four cohorts listed in Table6. The concentration of rHuPH20 used in this study was guided by datafrom the mini-pig study in Example 4 above in which TCZ was administeredSC in the presence and in the absence of either 2,000 or 6,000 U/mL(nominal concentrations) of rHuPH20. Results demonstrated a more rapidabsorption of TCZ administered SC from rHuPH20 containing TCZformulations. This effect on the absorption rate of TCZ was comparablewith both rHuPH20 concentrations. Analytical quantification of thedosing solution revealed an actual rHuPH20 concentration of 1,356 U/mL(instead of the nominal 2,000 U/mL). Therefore, a rHuPH20 concentrationof 1,500 U/mL was selected for the proposed clinical study.

TABLE 6 TCZ Dosage and Schedule Cohort IMP 1 TCZ (180 mg/mL) SCformulation single dose of 0.9 mL corresponding to a dose of TCZ 162 mgTCZ 2 TCZ (180 mg/mL)/rHuPH20 (1,500 U/mL) SC formulation, single doseof 0.9 mL corresponding to a dose of 162 mg TCZ and 1,350 U rHuPH20 3TCZ (180 mg/mL)/rHuPH20 (1,500 U/mL) SC formulation, single dose of 3.6mL corresponding to a dose of 648 mg TCZ and 5,400 U rHuPH20 4 TCZ (180mg/mL)/rHuPH20 (1,500 U/mL) SC formulation, single dose of 1.8 mLcorresponding to a dose of 324 mg TCZ and 2,700 U rHuPH20

The study consisted of a screening period (days −28 to −2), an in-clinicperiod (days −1 evening to 2 morning) with a single dose of study druggiven on day 1 and a follow-up period (between days 40 and 43).

Eligible subjects were admitted to the clinical research unit on day −1and predose assessments and procedures were performed. After a minimumfast of 4 hours, blood and urine samples were taken. After a light,standardized breakfast on the morning of day 1, subjects received theirTCZ SC injection in the right or left anterior thigh (midway between theanterior iliac crest and the cephalad border of the patella). Start andend time of each SC injection was recorded and individual injectionsites were photographed before and after injection.

After placement of the injection device, but before study druginjection, subjects had their pain assessed according to a 100 mmhorizontal visual analogue scale (VAS) and a categorical 6-point painself-assessment.

Subjects remained in the unit until the 24-hour PK assessments werecomplete and returned for PK and safety assessments as specified. Bloodsamples were drawn pre-dose and at 2, 8, 12, 24 and 36 hours post-dosefor the analysis of serum TCZ levels. Additional blood samples werecollected on days 3, 4, 5, 8, 11, 15, 18, 22, 29, 36 and at follow up.Blood samples for assessments of IL-6, sIL-6R, and CRP were drawn at thesame time points as samples for the PK analyses.

Subjects returned to the clinic between days 40 and 43 for follow-upprocedures including a physical examination, three serial 12-lead ECGs,vital signs and clinical laboratory tests.

Safety (clinical laboratory tests and vital signs) and PK/PD assessmentswere performed at regular intervals during the study. Spontaneousadverse events were recorded throughout the study. Subjects remained inthe unit until the 24-hour PK assessments were complete. Subjectsreturned for PK and safety assessments on specified days afterwards.

PK and PD samples were collected intensively. PK and PD parameters wereestimated with non-compartmental methods. A one way ANOVA was used toassess the effect of rHuPH20 on TCZ exposure. Safety and tolerabilitywas monitored throughout the study.

Results

Results of this study are depicted in FIGS. 8-13.

Pharmacodynamic Results:

CRP: Following administration of SC TCZ across all cohorts, mean CRPvalues decreased rapidly and reached a nadir at nominal times 168 and240 hours in Cohorts 1 and 2 and at 336 hours in Cohorts 3 and 4,although by the nominal time 168 hours nadir was approximately reachedin all cohorts. Thereafter, mean CRP values increased toward baselinevalues by nominal time 504 hours in Cohorts 1 and 2 and by 672 hours inCohort 4. Mean CRP values remained suppressed through 672 hour timepoint in Cohort 3, however the unscheduled follow-up sample revealedmean values which returned toward baseline. Cohorts 1 and 2 revealed asimilar change from baseline in mean CRP values while in Cohort 4 CRPvalues revealed a delay in time to return to baseline. In Cohort 3 meanchange from baseline values remained below baseline. A dose dependenteffect on mean CRP noncompartmental parameters was observed with a dosedependent decrease in mean AUC_(0-D29) for CRP observed across cohorts.Dose dependent changes in CRP T_(min) were also observed where a delayin mean T_(min) was observed with increasing dose. See FIG. 10.

IL-6: Following administration of SC TCZ with and without rHuPH20, meanIL-6 serum concentrations increased rapidly in all four cohorts andsubsequently declined gradually over time. In Cohorts 1 and 2, mean IL-6concentrations reached approximate baseline levels by nominal sampletime of 504 hours while in Cohort 4 mean IL-6 serum concentrationsreached approximately baseline values by the follow-up sample on days40-43. In Cohort 3, mean IL-6 values were elevated through the nominaltime 672 hours, but concentrations returned to approximate baselinevalues at the unscheduled follow-up sample. See FIG. 11.

sIL-6R: Following administration of SC TCZ with and without rHuPH20,mean sIL-6R serum concentration increased rapidly in all cohorts.Following maximal concentrations reached at nominal sampling time 240hours in Cohorts 1 and 2, mean sIL-6R concentrations subsequentlydeclined to approximately baseline levels by nominal time 672 hours. InCohort 4, mean sIL-6R serum concentrations decreased following maximalconcentration at nominal time 408 hours toward baseline values by thefollow-up sample on days 40-43. In Cohort 3, mean sIL-6R serumconcentrations increased rapidly following TCZ administrations andcontinued to increase across all sampling points reaching an observedmaximal concentration at the sampling time of 672 hours. See FIG. 12.

For IL-6 and sIL-6R noncompartmental parameters, mean AUC_(0-D29)increased with increasing dose across cohorts. Mean C_(max) revealed asimilar dose dependent increase. Observed time to maximum concentration(T_(max)) was prolonged with increasing dose.

In comparing the effect of rHuPH20 on PD response between Cohort 1 (162mg TCZ) and Cohort 2 (162 mg TCZ/1350U rHuPH20), the concentration-timeprofiles were similar between the two groups for all three PD parameters(CRP, IL-6, and sIL-6R). Mean PD (CRP, IL-6, and sIL-6R) AUC_(0-D29)parameters were similar between Cohorts 1 and 2 with AUC_(0-D29) ratiosof 99.6%, 100%, and 97.4% for CRP, IL-6, and sIL-6R, respectively.

Pharmacokinetic Results:

Results from Cohorts 1 and 2 (162 mg TCZ with and without PH20) indicatea trend towards an earlier T_(max) and slightly higher exposure (GMR[90% confidence intervals] for C_(max) and AUC_(0-inf) were 1.45[1.24-1.70] and 1.20 [1.00-1.44], respectively) in the presence ofrHuPH20 while TCZ serum concentrations in the elimination phase weresuperimposable for the two formulations. With the addition of rHuPH20 inCohort 2, there was a clear trend towards reduced variability (CV %) inthe PK parameters of TCZ (17.4 vs. 32.4 for C_(max) and 16.4 vs. 42.0AUC_(0-inf) with and without rHuPH20, respectively).

In Cohort 3 following administration of 648 mg TCZ/PH20, mean C_(max)and AUC_(0-inf) of TCZ were approximately 6.95- and 12.55-fold higherthan in Cohort 1 (162 mg TCZ), while the total dose administered wasonly 4-fold higher, reflecting the non-dose proportionality in the PK ofTCZ. The unscheduled follow-up sample taken for subjects in Cohort 3(mean actual time 1909±66.1 hours) revealed TCZ serum concentrationsbelow the limit of quantification for all subjects indicating thecomplete elimination of the single TCZ SC dose.

In Cohort 4 following administration of 324 mg TCZ/PH20, mean C_(max)and AUC_(0-inf) of TCZ were approximately 3.85- and 4.44-fold higherthan in Cohort 1 (162 mg TCZ), while the total dose administered wasonly 2-fold higher.

Plasma rHuPH20 concentrations were below the limit of quantification forall sampling points in all subjects indicating the use of the enzyme asa local permeation enhancer for the co-administered drug does not resultin quantifiable systemic exposures of the enzyme.

Pharmacokinetic/Pharmacodynamic Relationships:

sIL-6R and TCZ: The sIL-6R concentrations reached Cmax after TCZ reachedits Cmax for all 4 cohorts, with a delayed increase in sIL-6R levels asthe TCZ concentration increased creating a counter-clockwise hysteresisrelationship. The TCZ Cmax was reached at times ranging from 36 to 96hours after administration of TCZ across all cohorts, while sIL-6Rreached Cmax at nominal time 240 hours for Cohorts 1 and 2, nominal time672 hours for Cohort 3, and nominal time 408 hours for Cohort 4.

C-Reactive Protein and TCZ: As with sIL-6R, TCZ administration resultedin a delayed decrease of CRP, ie, the CRP nadir was reached after theCmax of TCZ. The CRP nadir was reached at nominal times 168 and 240hours in Cohorts 1 and 2 and by 336 hours in Cohorts 3 and 4 while theTCZ Cmax occurred at times ranging from 36 to 96 hours afteradministration of TCZ across all cohorts, creating a clockwisehysteresis relationship

Safety Results:

Sixty-one of the 68 reported adverse events were considered by theinvestigator to be possibly or remotely related to treatment with thestudy drug. Most were injection site adverse events, which were reportedonly by subjects who received TCZ with rHuPH20. There were no deaths, noserious adverse events, and no subjects withdrew from the study due toan adverse event. There did not appear to be a relationship between thenumber of subjects reporting adverse events, the presence or absence ofrHuPH20, or the dose of TCZ.

With the exception of mean white blood cell counts and neutrophilcounts, mean hematology parameters remained in the normal rangethroughout the study, as did mean total bilirubin, ALAT, and ASATconcentrations. Mean white blood cell counts and neutrophil counts wereback within reference ranges at the end of the study. Low neutrophilcount was also the most common marked laboratory abnormality reportedduring the study, reported by a total of 30 subjects across alltreatment groups. Eight of the subjects with markedly low neutrophilcounts also reported infections, which resolved with no sequelae. ECGreadings and vital signs were normal throughout the study for mostsubjects. There were no clinically relevant changes in serum IgE, IgG,IgM, and IgA levels. Neutralizing anti-TCZ antibodies were confirmed intwo subjects receiving 648 mg TCZ/rHuPH20. No subjects developedneutralizing anti-rHuPH20 antibodies. The SC injections were welltolerated in all cohorts, as evaluated by the Visual Analog Scale andpatient categorical self-assessment.

Conclusions

Pharmacokinetic and Pharmacodynamic Conclusions

-   -   Administration of TCZ with rHuPH20 resulted in a slightly        increased exposure with geometric mean ratios (90% confidence        intervals) for AUC_(0-inf) and C_(max) of 1.20 (1.00-1.44) and        1.45 (1.24-1.70), respectively, for Cohort 2 (162 mg        TCZ/rHuPH20) to Cohort 1 (162 mg TCZ) supporting the hypothesis        that rHuPH20 acts as a local permeation enhancer.    -   A clear trend towards lower PK variability in the presence of        rHuPH20 was observed.    -   A four-fold increase in administered TCZ dose in Cohort 3 (648        mg TCZ/PH20) resulted in 12.55-fold higher AUC_(0-inf) and        6.96-fold higher C_(max) with 648 mg TCZ/PH20 compared to 162 mg        TCZ in Cohort 1    -   A two fold increase in administered TCZ dose in Cohort 4 (324 mg        TCZ/PH20) resulted in 4.44-fold higher AUC_(0-inf) and 3.85-fold        higher C_(max) with 324 mg TCZ/PH20 compared to 162 mg TCZ in        Cohort 1.    -   The single SC TCZ doses assessed in Cohort 4 (324 mg) provided        mean AUC_(0-inf) of 10800±3220 μg·hr/mL and C_(D29) of 1.6±2.4        μg/mL and provided a C_(max) of 43.8±12.4 μg/mL.    -   The single SC TCZ doses assessed in Cohort 3 (648 mg) provided        mean AUC_(0-inf) of 29900±5280 μg·hr/mL and CD29 of 12.6±5.0        μg/mL and provided a C_(max) of 77.8±14.5 μg/mL.    -   The impact on the PD markers sIL-6R, IL-6 and CRP are comparable        for SC formulations containing 162 mg TCZ with and without        rHuPH20. Dose dependent changes in PD markers were observed with        increased doses from 162 mg to 648 mg TCZ/rHuPH20.

Safety Conclusions

-   -   Serious adverse events were not reported with SC doses of TCZ        with or without rHuPH20.    -   Tocilizumab-treatment was associated with a decrease in        neutrophils within 2 to 5 days of treatment. Mean neutrophil        counts returned to baseline from day 15 to follow-up in a dose        dependent manner.    -   Most other laboratory parameters ECGs, immunoglobulin levels and        vital signs recordings remained within the normal range        throughout the study.    -   Two subjects developed neutralizing anti-TCZ antibodies    -   No subjects developed neutralizing anti-rHuPH20 antibodies.    -   SC injections were well tolerated based on the Visual Analog        Scale and subject categorical self-assessment.

Example 6 SQ Administered Anti-IL-6R Antibody for sJIA

This example describes the use of subcutaneously administered anti-IL-6Rantibody (TCZ) to treat systemic juvenile idiopathic arthritis (sJIA). ATCZ formulation with 180 mg/mL TCZ and no hyaluronidase (see Table 2 inExample 4) is subcutaneously administered in this example.

This is a phase 1b open label multi-center study to investigatepharmacokinetics, pharmacodynamics, efficacy and safety of tocilizumabfollowing subcutaneous administration in patients with active sJIA.Patients to be treated in this study will be children age 2 up to andincluding age 17 sJIA≥6 months persistent activity who have had aninadequate clinical response to NSAIDs and corticosteroids (CS) due totoxicity or lack of efficacy will be treated herein.

In WA18221 study, TCZ was given at 12 mg/kg in patients with BW<30 kgand 8 mg/kg in patients with BW≥30 kg every 2 weeks for 12 weeks.Comparable PK exposures were achieved for two body weight groups (FIG.23A). Comparable sIL-6R profiles (FIG. 23B), CRP normalization pattern(FIG. 23C), and ESR profile (FIG. 23D) were observed for two BW groups.The comparable PK-PD profiles from WA18221 study resulted in acceptableefficacy and safety across the entire body weight range. Of all TCZtreated patients, 85.3% patients met primary endpoint of a JIA ACR30response and absence of fever at Week 12 in contrast to 24.3% of theplacebo patients demonstrating a statistically significant difference(p<0.0001). At week 12, JIA ACR 30, 50, 70 and 90 responses were 90.7%,85.3%, 70.7% and 37.7%, respectively, compared to 24.3%, 10.8%, 8.1% and5.4% from placebo group, respectively.

To further examine if dose was adequate in WA18221 study, the PKexposure-efficacy relationship was analysed by PK exposure quartiles. Atweek 12, AUC_(2week) increased by 2.3-fold from quartile 1 (849±147μg·day/ml) to quartile 4 (1,925±187 μg·day/ml) (Table 7). At week 52,Cmin in quartile 4 (108±12 μg/ml) was 3.6-fold greater than in quartile1 (30±16 μg/ml) (Table 7). Although the study was not powered to compareefficacy in each of the 4 quartiles, proportions of patients whoachieved JIA ACR30/50/70/90 responses appear comparable across 4quartiles (Table 7), suggesting the exposures were at the plateau of theexposure-response curve. Limited data in each quartile did not showclear trend towards a higher incidence of AEs or serious AEs with higherTCZ exposure from quartile 1 to quartile 4 (AUC_(2week), C_(max) orC_(min)) (Table 8).

TABLE 7 Efficacy End Points by PK Quartile at Week 12 and Week 52 inPatients Assigned to TCZ at Baseline Quartile 1 Quartile 2 Quartile 3Quartile 4 Week 12 n = 19 n = 19 n = 19 n = 18 AUC_(2 weeks) 849 ± 1471,178 ± 68.4 1,445 ± 105 1,925 ± 187 (μg · d/ml)² JIA ACR30, 16 (84.2)17 (89.5) 18 (94.7) 17 (94.4) n (%) JIA ACR50, 15 (78.9) 16 (84.2) 16(84.2) 16 (94.4) n (%) JIA ACR70,  9 (47.4) 15 (78.9) 14 (73.7) 15(83.3) n (%) JIA ACR90,  5 (26.3)  7 (36.8) 10 (52.6) 16 (33.3) n (%)Quartile 1 Quartile 2 Quartile 3 Quartile 4 Week 52 n = 15 n = 14 n = 16n = 13 C_(min) 30.0 ± 16.3 62.5 ± 4.1 81.9 ± 6.0 108 ± 12.0 (μg/ml) JIAACR30, 15 (100)  14 (100) 16 (100) 13 (100) n (%) JIA ACR50, 13 (86.7)14 (100) 16 (100) 13 (100) n (%) JIA ACR70, 11 (73.3)  11 (78.6) 16(100) 13 (100) n (%) JIA ACR90,  8 (53.3)   8 (57.1)  13 (81.3)   8(61.5) n (%) Quartiles are defined as those patients falling within0%-≤25%, >25%-≤50%, >50%-≤75%, and >75%-100% of exposures. Patients whowere randomly assigned to placebo treatment in study part 1 areexcluded. Patients who had missing PK samples at week 52 were excludedfrom the summary. Mean ± SD for AUC_(2 weeks) and C_(min) are presented.

TABLE 8 Percentage of patients reporting adverse events by body systemand preferred term to week 12 by AUC_(2 weeks) and to Week 52 by C_(min)exposure quartiles Quartile 1¹ Quartile 2¹ Quartile 3¹ Quartile 4¹ Week12 (n = 19) (n = 19) (n = 19) (n = 18) AUC_(2 weeks) 849 ± 147 1,178 ±68 1,445 ± 105 1,925 ± 187 (μg · d/ml)² All body 19 (100%) 16 (84%) 17(865%) 14 (78%)  systems³ Infections and 11 (58%)   8 (42%) 6 (32%) 9(50%) infestation Gastrointestinal 3 (16%)  5 (26%) 2 (11%) 4 (22%)disorders Skin and 4 (21%) 1 (5%) 3 (16%) 4 (22%) subcutaneous tissuedisorders Nervous 3 (16%) 1 (5%) 2 (11%) 2 (11%) system disordersRespiratory, 3 (16%) 1 (5%) 2 (11%) 1 (6%)  thoracic, and mediastinaldisorders Serious adverse 3 (16%) 0 (0%) 0 (0%)  0 (0%)  events Quartile1 Quartile 2 Quartile 3 Quartile 4 Week 52 (n = 15) (n = 14) (n = 16) (n= 13) C_(min) 30 ± 16 63 ± 4 82 ± 6 108 ± 12 (μg · d/ml)^(2,4) All body15 (100) 14 (100) 16 (100) 11 (85)  systems³ Infections and 10 (67)  12(86)  15 (94)  8 (62) Infestation Gastrointestinal 7 (47) 3 (21) 5 (31)5 (39) disorders Skin and 5 (33) 3 (21) 7 (44) 7 (54) subcutaneoustissue disorders Nervous 4 (27) 3 (21) 3 (19) 4 (31) system disordersRespiratory, 5 (33) 2 (14) 5 (31) 6 (46) thoracic, and mediastinaldisorders Serious adverse 4 (27) 1 (7)  2 (13) 1 (8)  eventsAUC_(2 weeks), area under the serum concentration-time profile over 2weeks of the dosing interval at steady state; C_(min), minimumconcentration of drug at week 52 (predose concentration). Values are n(%) unless indicated otherwise. Patients who were assigned to placebotreatment in study part 1 were excluded. Patients who had missing PKsamples at week 52 were excluded from the summary. ¹Quartiles 1, 2, 3,and 4 are the first (0-<25%), second (>25-<50%), third (>50-<75%), andfourth (>75-100%) quartiles of individual exposure parameters as listed.²Mean ± standard deviation, AUC_(2 weeks), and C_(min) are presented.³Total patients with at least one adverse event are included. Only themost frequent adverse events are presented. ⁴C_(min) quartiles includeonly patients with nonmissing serum concentrations randomly assigned toTCZ at baseline

In study WA18221, TCZ 12 mg/kg for patients <30 kg and 8 mg/kg forpatients ≥30 kg, was given as an W infusion every 2 weeks. The scatterplots of C_(min) at steady state (Week 12) across body weight from10.0-112.7 kg showed that TCZ exposures are independent of body weight(FIG. 15). The mean PK model predicted Cmin is summarized in Table 9.

TABLE 9 Model simulated PK exposures for various dose regimens Bodyweight (sample size), AUC_(4 week), C_(min), Dose Regimen (route) kg μg· d/mL μg/mL 12 mg/kg Q2W (IV)^(a) <30 (38) 2692 ± 852 61 ± 26(1116-4354) (17-117) 8 mg/kg IV Q2W (IV)^(a) ≥30 (37)  2674 ± 818 55 ±21 (1144-4824) (10.9-100) All patients in All body 2682 ± 830 58 ± 23WA18221^(a) weight (1116-4354) (10.9-117) 162 mg QW (SC)^(b) ≥30 (37) 1810 ± 600 58 ± 20 (816-3244) (22-107) 162 mg Q2W (SC)^(b) <30 (38) 1398± 424 29 ± 13 (798-2202) (12-61) 162 mg QW (SC)^(b) <30 (38) 3092 ± 1020100 ± 35 (1416-5628) (45-188) 162 mg Q10D (SC)^(b) <30 (38) 1784 ± 58158 ± 2 (825-3231) (25-112) ^(a)Summary of PK parameters estimated bypopulation analysis of data from study WA18221 follwing IV dosing;AUC_(2 week) was multiplied by 2 in order to compare with other SCregimens. ^(b)Summary of simulated PK parameters for individual patientsfrom Study WA18221 following SC dosing

Available subcutaneous formulation is in a 1 mL prefilled syringedelivering 0.9 mL 162 mg TCZ per injection. Thus the SC dose in thepresent study is a flat dose regimen across wide BW range. The initialdose for the present study has been selected based on the modeling andsimulation and explained below.

In study WA18221, pharmacokinetic profile following W administration wasdescribed by a 2-compartment model with both a saturable(Michaelis-Menten elimination) and a non-saturable first orderelimination pathway from central compartment. The PK dispositionparameters were well characterized (total clearance (CL; L/d), volume ofdistribution of the central compartment (Vc; L), volume of distributionof the peripheral compartment (Vp; L), intercompartmental clearance (Q;L/d), the Michaelis-Menten constant (Km; mg/L) and the maximum rate ofthe saturable elimination process (Vmax; mg/d)). In study NP22623, 162mg TCZ was administered in the adult RA patients as either weekly (QW)and every other week (Q2W) dosing for 12 weeks in a total of 29patients. Empirical modeling of the PK data from NP22623 providedsubcutaneous absorption PK parameters (absorption rate constant Ka andbioavailability F) in RA patients. Under the assumption that theseabsorption PK parameters are similar to the absorption PK parameters inpediatric sJIA patients, and disposition PK parameters from WA18221study are independent of the route of administration, the PK exposureswere simulated for sJIA patients <30 kg and ≥30 kg following multipledose administration up to a steady state. The simulated PK profiles forW and SC administration are illustrated in FIG. 14. The PK modelsimulated C_(min) values versus body weight are shown in FIGS. 15 to 18.Calculated PK parameters based on the simulated PK profiles aresummarized in Table 9.

As expected, W dosing regimen exhibited more fluctuation between thepeak and the trough concentration during a dosing interval, whereas forSC dosing, fluctuation between peak and trough is much smaller (FIGS.14A and 14B).

Based on PK simulation, for sJIA patients weighing ≥30 kg, 162 mg QWprovided mean±SD C_(min) (58±20) which is comparable to 58±23 fromWA18221 study (Table 9). Individual Cmin data are also within 90%confidence limit from WA18221 study (FIGS. 16 to 18).

Based on PK simulation, for patients with BW<30 kg, 162 mg Q2W or 162 mgQW resulted in the mean±SD Cmin lower (29±13) or higher (100±35) thanthe average Cmin (58±23) from study WA18221, respectively. For 162 mgQ2W dosing, although all data are with min-max range from WA18221, 26%(10 of 38) Cmin values are below the lower 90% confidence bound fromWA18221 study (FIG. 16). For 162 mg QW dosing, 21% (8 of 38) Cmin dataare above the upper 90% confidence bound from WA18221 study (FIG. 17).

Based on PK model simulation, for patients with BW<30 kg, 162 mg SCinjection every 10 days (Q10D) is predicted to provide mean±SD Cmin(58±22) being comparable to the data (58±23) from WA18221 study (Table9). There are only 2 of 38 (5%) C_(min) values outside of the 90%confidence bound (FIG. 18).

Thus, the following treatment protocols will be used:

Group 1: Patients with body weight (BW)≥30 kg will receive 162 mg TCZsubcutaneous (SC) injections weekly (QW) for 14 weeks (13 doses). N=12

Group 2: Patients with BW<30 kg will receive 162 mg TCZ SC injectionsevery 10 days (Q10D) for 14 weeks (9 doses). N=12

The treatment period will last for 14 weeks. During the treatmentperiod, stable NSAIDs and MTX will be continued unchanged throughout 14weeks of the study. Oral steroid dose will remain stable up to 6 weeksfrom first dose of TCZ at baseline. Steroid tapering will be allowedfrom week 6 onwards at discretion of the investigator. For CS reduction,no more than 20% reduction per week is recommended. The investigator mayadjust or discontinue concomitant MTX, CS and/or NSAIDs treatmentaccording to standard of care for reasons of safety at any time. Thefollow-up visit will be performed at 2, 4 and 8 weeks after last SCdosing.

Pharmacokinetic parameters will include C_(max), C_(min), T_(max),T_(1/2), and AUC_(τ) at steady state.

Pharmacodynamic parameters will include sIL-6R, CRP, and/or ESRconcentration.

Efficacy will be evaluated by the following:

Proportion of patients with JIA ACR30/50/70/90 responses at Week 14 withand without absence of fever; and other efficacy parameters asappropriate.

It is anticipated that the anti-IL-6R antibody (TCZ) will be effectivein sJIA patients with body weight ≥30 kg when administered as a fixeddose of 162 mg every week (QW) by SQ administration, e.g., for up to 14weeks.

It is further anticipated that the anti-IL-6R antibody (TCZ) will beeffective in sJIA patients with body weight <30 kg when administered asa fixed dose of 162 mg every 10±1 days (Q10D) by SQ administration,e.g., for up to 14 weeks. Alternative dosing regimens include 162 mgevery week (QW) or every two weeks (Q2W).

Example 7 SQ Administered Anti-IL-6R Antibody for pcJIA

Anti-IL-6R antibody (TCZ) is subcutaneously administered to patientswith polyarticular course juvenile idiopathic arthritis (pcJIA). Theformulation with 180 mg/mL TCZ and no hyaluronidase disclosed in Table 2in Example 4 is administered herein.

This is a phase Ib open label multi-center study to investigatepharmacokinetics, pharmacodynamics, efficacy and safety of tocilizumabfollowing subcutaneous administration in patients with active pcJIA.Patients to be treated in this study will be children aged 2-17 yearswith at least 6 months active pcJIA (including either rheumatoid factor(RF)-positive or RF-negative polyarthritis subsets, or the extendedoligoarticular JIA subset), with at least 5 joints with active arthritis(at least 3 of the active joints having limitation of motion) who havehad an inadequate clinical response to methotrexate (MTX) due to lack ofefficacy or toxicity, who are receiving standard of care, either with orwithout NSAIDs, low dose corticosteroids or concomitant MTX.

Up to 30% of patients enrolled in this study may have had previoustreatment with a biologic disease modifying anti-rheumatic drug(biologic DMARD).

TCZ has been approved for treatment of pcJIA in Japan based on the phase3 study MRA318JP conducted in Japanese patients. Objectives of the studywere to determine the efficacy, safety, PK and PD of TCZ following 8mg/kg TCZ infusion every 4 weeks for 12 weeks (3 infusions). It wasobserved, that the clinical response, expressed as probability to reacha pcJIA50 or pcJIA70 score, was lower in children with a lowerbodyweight compared to patients with a higher body weight. After 12weeks of treatment with TCZ 8 mg/kg every 4 weeks: 88% of patientsweighing <30 kg vs 100% of the patients weighing ≥30 kg reached apcJIA50 score (FIG. 19A); and 38% of patients weighing <30 kg vs 80% ofpatients weighing ≥30 kg reached pcJIA70score (FIG. 19B).

This noticeable difference in JIA ACR response rate was associated witha visible trend towards lower systemic exposure (AUC_(4week)) to TCZ insubjects with lower body weight, particularly below a body weight ofapproximately 30 kg. In contrast, in patients with a body weight higherthan 30 kg exposure appeared to be more or less independent of bodyweight (FIG. 20A).

The PK of TCZ from MRA318 TCZ was described by a two-compartmentdisposition model with parallel first-order (linear CL) andMichaelis-Menten elimination (nonlinear or concentration-dependent CL)kinetics. For the dose of 8 mg/kg administered every 4 weeks, thecontribution of nonlinear CL to AUC was small and had no relevant impacton C_(max). The most pronounced impact of the concentration-dependent CLcomponent on the PK of TCZ was observed for C_(min). The C_(min) valueswere close to the mean K_(M) value of the nonlinear CL component. Thus,C_(min) values were in a concentration range where small changes inserum TCZ concentrations result in a relative large change in nonlinearCL.

FIGS. 24A-D show the PK, sIL-6R, CRP and ESR profiles over time during12 weeks of treatment. sIL-6R levels increased over time and reachedstable condition at week 12 (FIG. 24B). CRP levels fluctuated during adosing interval with elevation prior to next dose (FIG. 24C). ESRdecreased by week 4 and stay low after week 8 (FIG. 24D). Analysis ofPK-PD relationship indicated that when the serum TCZ concentration wasat or above (1 μg/mL), CRP and ESR were low and sIL-6R saturation washigh.

Following administration of TCZ 8 mg/kg IV Q4W to pcJIA patients instudy MRA318JP, prior to the next infusion at weeks 4, 8 and 12,approximately 35 to 39% of patients had TCZ Cmin<1 μg/mL (Table 10).Although most children in MRA318JP reached the ACR30 endpoint at Week12, children with non-measurable TCZ levels at Cmin were much lesslikely to achieve JIA ACR 70 than those with measurable Cmin TCZ levels(25% vs 73%). The majority of children with non-measurable TCZ at Cmin,and not achieving the best efficacy responses had lower body weights(<30 kg).

TABLE 10 Mean ± SD Serum TCZ Concentrations and % of Patients in SerumTCZ Concentration Less than 1 μg/mL Mean ± SD % of patients with Time ofVisit TCZ, μg/mL TCZ <1 μg/mL 0 (pre dose) 0 NA 0 (post dose)  145 ±37.5 0 1 42.9 ± 13.3 0 2 20.2 ± 8.75 0 4 3.83 ± 3.47 38.9 6 22.6 ± 8.595.6 8 5.71 ± 5.71 35.3 10 22.8 ± 9.23 5.9 11 12.7 ± 7.01 17.6 12 4.88 ±4.68 38.9

The population PK analysis was developed based data from MRA318JP andinterim PK data from WA19977 (117 patients). In study NP22623, 162 mgTCZ was administered in the adult RA patients as QW or Q2W dosing for 12weeks in a total of 29 patients. Empirical modeling of the PK data fromNP22623 provided subcutaneous absorption PK parameters (absorption rateconstant Ka and bioavailability F) in RA patients. Under the assumptionthat these absorption PK parameters are similar to the absorption PKparameters in pediatric pcJIA patients, and disposition PK parametersfrom WA19977 study are independent of the route of administration, thePK exposures were simulated for pcJIA patients <30 kg and ≥30 kgfollowing multiple dose administration up to a steady state. Thesimulated PK profiles for IV and SC administration are illustrated inFIGS. 21A and 21B, respectively. TCZ concentrations following IV and SCadministration during a dosing interval of 4 weeks at steady stateappear to be approximately at similar levels. The model simulated TCZexposure parameters (AUC_(4week), C_(min) and C_(max)) are shown inTable 11. SC dose of 162 mg Q2W for both BW<30 kg and BW≥30 kg patientsappear to be appropriate to produce comparable AUC_(4week) to theWA19977 study (Table 11). Therefore, the proposed SC dose for Group 1 is162 mg Q2W for all patients.

TABLE 11 Model Simulated Serum TCZ PK Exposure Parameters for SC and IVDosing Regimens for Patients in WA19977 Study AUC_(4 week), C_(max),C_(min), WA19977 BW, kg N μg · d/mL μg/mL μg/mL 8 mg/kg Q4W^(a) <30 20424 ± 143 113 ± 24 0.3 ± 0.6 (205-754) (74-164) (0-2.6) 10 mg/kg Q4W^(a)<30 19 825 ± 226 185 ± 36 2.4 ± 2.5 (328-1359) (132-249) (0-9.2) 8 mg/kgQ4W^(a) ≥30 78 1031 ± 359 171 ± 38 5.3 ± 6.4 (485-2058) (79-265)(0.1-29) 162 mg Q2W^(b) <30 39 945 ± 377 43 ± 14 20 ± 12 (299-2111)(19-87) (1.8-57) 162 mg Q2W^(b) ≥30 78 604 ± 178 28 ± 7 12 ± 5 (148-985)(11-42) (0.6-28) Mean ± SD (min-max) presented ^(a)Summary of PKparameters estimated by population analysis of data from study WA19977follwing IV dosing; AUC_(2 week) was multiplied by 2 in order to comparewith other SC regimens. ^(b)Summary of simulated PK parameters forindividual patients from Study WA19977 following SC dosing.

Thus, 162 mg of TCZ is administered subcutaneously every 2 weeks (Q2W)to patients with pcJIA (N=24). The treatment period will last for 14weeks. During the treatment period, stable NSAIDs and MTX will becontinued unchanged throughout 14 weeks of the study. No tapering ofcorticosteroids, NSAIDs or methotrexate can occur during the studyexcept for safety reasons. PK, PD, efficacy parameters will be assessedat the scheduled time points. The follow-up visit will be performed at 4and 8 weeks after last SC dosing.

It is anticipated that the anti-IL-6R antibody (TCZ) will be effectivein pcJIA patients when administered as 162 mg dose every 2 weeks (Q2W)by SQ administration, e.g., for up to 14 weeks.

Example 8 SQ Administered Anti-IL-6R Antibody for Systemic Sclerosis

This is a Phase 2/3, multicenter, randomized, double-blind,placebo-controlled, two-arm, parallel-group trial in patients withsystemic sclerosis (SSc). A TCZ formulation with 180 mg/mL TCZ and nohyaluronidase (see Table 2 in Example 4) is subcutaneously administeredto SSc patients in this study. The primary endpoint, the change inmodified Rodnan skin score (mRSS) from baseline at Week 24, will beevaluated at Week 24. There will be a 48-week blinded period followed bya 48-week open-label period.

Patients will be randomized in a 1:1 ratio to receive either 162 mg ofSC TCZ weekly (QW) (Group A) or SC placebo QW (Group B) for 48 weeks.The primary analysis will occur when all patients have reached Week 24.

Starting at Week 48, all patients will receive open-label treatment with162 mg of TCZ subcutaneously QW and no patient will receive a placeboinjection.

Efficacy parameters will be assessed, starting at baseline to Week 96,as described in the schedule of assessments.

Target Population

Patients must meet the following criteria for study entry:

-   -   Ability and willingness to give written informed consent and        comply with the requirements of the study protocol    -   Diagnosis of SSc, as defined using the American College of        Rheumatology criteria (1980)    -   Disease duration of ≤60 months (defined as time from the first        non-Raynaud phenomenon manifestation)    -   Age ≥18 years at baseline    -   ≥15 and ≤40 mRSS units at the screening visit    -   Uninvolved skin at one of the following locations:        -   Front of the middle region of the thighs        -   Lower part of the abdomen below the navel except for the            2-inch area directly around the navel        -   Outer area of the upper arms (if a caregiver is giving the            patient injections)    -   Active disease defined as at least one A criterion and one B        criterion each:        -   Criteria A at screening            -   Increase ≥3 in mRSS units at screening compared with the                last visit within previous 1-6 months            -   Involvement of one new body area with ≥2 mRSS units at                screening compared with the last visit within the                previous 1-6 months            -   Involvement of two new body areas with ≥1 mRSS units at                screening compared with the last visit within the                previous 1-6 months            -   Other documentation of worsening skin thickening at                screening compared with the last visit within the                previous 1-6 months consistent with the progression of                skin thickening described in the above criteria using                mRSS            -   Presence of 1 or more TFRs at screening        -   Criteria B at screening            -   High-sensitivity C-reactive protein ≥1 mg/dL            -   Erythrocyte sedimentation rate ≥28 mm/hr            -   Platelet count (≥330×10³/μL)    -   Treatment with oral corticosteroids (≤10 mg/day of prednisone or        equivalent) is permitted if the patient is on a stable dose        regimen for ≥2 weeks prior to and including at baseline.    -   Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is        permitted if the patient is on a stable dose regimen for ≥2        weeks prior to and including at baseline.    -   Angiotensin-converting enzyme inhibitors, calcium-channel        blockers, protein-pump inhibitors, and/or oral vasodilators are        permitted if the patient is on a stable dose for ≥4 weeks prior        to and including at baseline.    -   If female of childbearing potential, the patient must have a        negative pregnancy test at screening and the baseline visit.

Efficacy Outcome Measures

The primary efficacy endpoint is the change in modified Rodnan skinscore (mRSS) from baseline at Week 24. Skin thickness will be assessedby palpation and rated using a score from 0 (normal) to 3 (severe skinthickening) across 17 different sites. The total score is the sum of theindividual skin scores in the 17 body areas (e.g., face, hands, fingers;proximal area of the arms, distal area of the arms, thorax, abdomen;proximal area of the legs, and distal area of the legs, feet), giving arange of 0-51 units. The instrument has been validated for patients withSSc.

The secondary efficacy endpoints for this study are as follows:

-   -   Change in Scleroderma Health Assessment Questionnaire-Disability        Index (SHAQ-DI) score from baseline at Weeks 24 and 48    -   Change in 28 tender joint count (TJC) from baseline at Weeks 24        and 48 in patients with joint involvement at baseline    -   Change in the patient's global assessment from baseline at Weeks        24 and 48    -   Change in the clinician's global assessment from baseline at        Weeks 24 and 48    -   Change in Functional Assessment of Chronic Illness        Therapy-Fatigue (FACIT)-Fatigue score from baseline at Weeks 24        and 48    -   Change in Pruritus 5-D Itch Scale from baseline at Weeks 24 and        48    -   Change in mRSS from baseline at Week 48    -   Proportion of patients with change from baseline in the mRSS at        Week 48 greater than or equal to the change from baseline in the        mRSS at Week 24

It is anticipated that subcutaneously administered TCZ as disclosedherein will improve cutaneous sclerosis, improve physical function,and/or slow progression of organ damage in SSc patients treated asdisclosed, relative to placebo-treated patients. For example, the TCZshall achieve the primary efficacy endpoint (change in mRSS at week 24)and/or any one or more of the secondary endpoints.

Example 9 SQ Administered Anti-IL-6R Antibody for Giant Cell Arteritis

This example describes the use of subcutaneously administered anti-IL-6Rantibody (TCZ) to treat giant cell arteritis (GCA). The TCZ formulationwith 180 mg/mL TCZ and no hyaluronidase described in Table 2 in Example4 is used to treat patients with GCA (new onset or refractory GCA).

The protocol for treating patients with GCA is shown in FIG. 22. Theproposed study is multicentre, randomized, double-blind,placebo-controlled in patients diagnosed with GCA. Patients may beeither new onset or refractory (i.e. GCA patients who have respondedinadequately to previous therapy with corticosteroids (CS)). The primaryendpoint will be CS free sustained remission at 9 months. Remission isdefined as absence of signs and symptoms and normalization of acutephase response. Sustained is defined as absence of flare followinginduction of remission. Patients achieving the primary endpoint at 9months will have achieved remission within 3 months and maintained theirremission for at least 6 months whilst being able to taper off their CS.Secondary endpoints at 9 months include time to GCA disease flare afterclinical remission, cumulative CS dose, quality of life and change inacute phase reactant and hemoglobin.

Two doses of subcutaneously administered TCZ will be used:

-   -   162 mg every week (qw); and    -   162 mg every other week (q2w).

Patients will be randomized in a 2:1:1 ratio (100:50:50) to receiveeither 162 mg of SC TCZ qw, 162 mg of SC TCZ q2w or SC placebo for 9months in a double blind fashion. In addition, all patients will receivebackground CS therapy and follow a CS tapering regimen over a 6 monthperiod (see Table 12). Refractory subjects will enter the study at 10 mghigher than the dose that previously controlled the disease and continuethe trial glucocorticoid taper outlined from the prednisone dose atentry. In the absence of relapse, this schedule will result in aglucocorticoid dosage below 5 mg after 4 months and no glucocorticoiduse after 6 months.

TABLE 12 Prednisone Schedule: New Onset Patients Daily prednisone dose,both arms Week (mg/day) 1 60 2 60 3 50 4 40 5 30 6 25 7 20 8 17.5 9 1510 12.5 11 10 12 9 13 8 14 7 15 6 16 5 17 4 18 4 19 3 20 3 21 2 22 2 231 24 1

At month 9, all patients may enter part 2 (open label extension) of thestudy. Patients who meet the primary endpoint will be required to stoptheir subcutaneous injections and be followed for maintenance ofresponse. Patients who do not meet the primary endpoint, will have theoption to escape to investigator-led therapy that can include open labelTCZ. The purpose of the open label extension is to describe the longterm safety and efficacy of a course of TCZ in GCA, to describe longterm steroid sparing effect of TCZ and its sequelae in terms of CSrelated adverse events, and to describe a potential requirement formaintenance of TCZ therapy beyond 9 months.

The target population for this study is adult patients with GCA. Newonset and relapsed/refractory GCA patients will be eligible.

Diagnosis of GCA is according to the following criteria

-   -   Westergreen erythrocyte sedimentation rate (ESR)>40 mm/hour    -   Unequivocal cranial symptoms of GCA (new onset localized        headache, scalp or temporal artery tenderness, ischemia-related        vision loss, or otherwise unexplained mouth or jaw pain upon        mastication)    -   At least one of the following:        -   Temporal artery biopsy revealing features of GCA        -   Symptoms of polymyalgia rheumatica (PMR), defined as            shoulder and/or hip girdle pain associated with inflammatory            morning stiffness        -   Evidence of large-vessel vasculitis by angiography or            cross-sectional imaging study such us magnetic resonance            angiography (MRA), computed tomography angiography (CTA), or            positron emission tomography-computed tomography angiography            (PET-CTA)    -   New Onset or refractory GCA is classified according to the        following criteria        -   New onset: active GCA diagnosis (clinical signs or symptoms            and ESR>40 mm/hr) made within 4 weeks of baseline visit            (irrespective of whether CS initiated or active disease            activity at baseline visit)        -   Refractory: diagnosis made >4 weeks prior to baseline visit            and active GCA (clinical signs and symptoms and ESR>40            mm/hr) within 4 weeks baseline irrespective of CS treatment

It is anticipated that subcutaneously administered TCZ as disclosedherein will effectively treat GCA, for example by reducing GCA signs andsymptoms, maintaining clinical remission, and/or reducing or stoppingcorticosteroid use in the patient with GCA.

1. A method of inhibiting progression of structural joint damage in arheumatoid arthritis patient comprising subcutaneously administering afixed dose of 162 mg of an anti-IL-6R antibody to the patient every twoweeks, wherein structural joint damage at week 24 or week 48 is found tobe inhibited.
 2. The method of claim 1 wherein the rheumatoid arthritispatient is a disease modifying anti-rheumatic drug (DMARD)-inadequateresponder.
 3. The method of claim 1 wherein the rheumatoid arthritispatient is a tumor necrosis factor (TNF)-inhibitor-inadequate responder.4. The method of claim 1 wherein the rheumatoid arthritis patient ismethotrexate naive or has discontinued methotrexate.
 5. The method ofclaim 1 which further comprises administering to the patient one or moreadditional drug which treats the rheumatoid arthritis.
 6. The method ofclaim 5 wherein the additional drug is selected from the groupconsisting of: immunosuppressive agent, non-steroidal anti-inflammatorydrug (NSAID), disease modifying anti-rheumatic drug (DMARD),methotrexate (MTX), anti-B-cell surface marker antibody, anti-CD20antibody, rituximab, tumor necrosis factor (TNF)-inhibitor,corticosteroid, and co-stimulatory modifier.
 7. The method of claim 6wherein the additional drug is a non-biological DMARD.
 8. The method ofclaim 6 wherein the additional drug is a non-steroidal anti-inflammatorydrug (NSAID).
 9. The method of claim 6 wherein the additional drug is acorticosteroid.
 10. The method of claim 1 wherein the anti-IL-6Rantibody is tocilizumab.
 11. (canceled)
 12. A method of treatingrheumatoid arthritis in a patient comprising subcutaneouslyadministering tocilizumab to the patient, wherein the tocilizumab isadministered as a fixed dose of 162 mg per dose every week or every twoweeks.
 13. A method of treating juvenile idiopathic arthritis (JIA) in apatient comprising subcutaneously administering an anti-IL-6 receptor(IL-6R) antibody to the patient in an amount effective to treat the JIA.14. The method of claim 13 wherein the JIA is systemic JIA (sJIA) andthe effective amount is 162 mg every week if the patient's weight is ≥30kilograms and 162 mg every 10 days if the patient's weight is <30kilograms.
 15. The method of claim 13 wherein the JIA is polyarticularcourse juvenile idiopathic arthritis (pcJIA) and the effective amount is162 mg every two weeks.
 16. A method of treating a fibrotic disease in apatient comprising subcutaneously administering an anti-IL-6 receptor(IL-6R) antibody to the patient in an amount effective to treat thefibrotic disease.
 17. The method of claim 16 wherein the fibroticdisease is systemic sclerosis.
 18. A method of treating giant cellarteritis (GCA) in a patient comprising subcutaneously administering ananti-IL-6 receptor (IL-6R) antibody to the patient in an amounteffective to treat the GCA.
 19. The method of claim 18 wherein theantibody is administered as a fixed dose of 162 mg per dose.
 20. Themethod of claim 19 wherein the 162 mg fixed dose is administered everyweek or every two weeks.